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Sgt. Erik Dexter began noticing changes in his battle buddy's behavior almost immediately.
Erik and Sgt. Loyd Sawyer had joined the Army in 2004. That's not all they had in common — they both had backgrounds as civilian funeral directors, and had children about the same age.
Within an hour of Erik's arrival at Fort Lee, Va., Loyd had invited him over for barbecue, beer and what would become constant, good-natured ribbing.
Then they deployed to Iraq together for six months in 2006, with Loyd processing the remains of 300 dead Americans with his mortuary affairs unit of the 111th Quartermaster Company at Joint Base Balad, and Erik processing about 60 at Combat Outpost Speicher.
"When we got back, it was just a slow regression," Erik said. "He was not the same guy I first met. His mind is nowhere near as focused as it used to be. I was just looking at him going, 'What happened?' "
The former multi-tasker could not seem to accomplish the most basic chores, though the intense look of concentration on his face showed he was trying. The man who instinctively made new soldiers feel at home and old soldiers feel cared for could not take care of himself well enough to take care of anybody else.
"Can you give me a hug?" the 6'4" jokester asked Erik during a morning formation shortly after they returned from Iraq. "I was curled up on the floor last night with my dog Sophie licking my head."
Erik quickly realized Loyd wasn't kidding. He needed help.
When Loyd returned home, he displayed classic symptoms of post-traumatic stress disorder. His nightmares were so bad that he didn't sleep — at all. A whiff of diesel or a loud noise sparked flashbacks. He couldn't be around other people. He couldn't relate to his wife or two boys. He reacted to everything — a question, a hug, a smile — with anger.
His tour had been filled with mortar attacks, including a rocket that crashed into the windshield of a truck he was driving, as well as processing the bodies of people he knew. Once, a Turkish airplane crashed not 1,000 meters from his mortuary affairs unit, and he spent the next three days packing the still-smoking remains of passengers into body bags.
After months of yelling at his wife Andrea, spending nights crying with his dog, avoiding his kids and refusing to participate in activities he used to enjoy — like barbecues and trips to Disneyworld — he finally came to realize he needed help.
"He knew that something was wrong, and he was very willing to seek treatment," Andrea said.
He reached out to his chain of command.
"His first sergeant took me seriously when I called for help," Andrea said. "He called Loyd in the next morning and sent him to see [Army Community Service] about anger management, and they sent him to social services."
His squad leader worked to keep him busy in a daily routine that would bring no surprises. He made sure Loyd had time to go to his appointments.
Then he arrived at the mental health clinic at Fort Lee. And things began to go awry.
No room at Mental Health
Andrea had called Loyd's first sergeant in early March 2007, but no mental health appointments were available. Instead, he began anger-management classes April 2 without anyone talking to him about his symptoms.
After the first session, the class leader told Loyd he needed to go to mental health. He called for an appointment. They said they could see him in mid-May — six weeks out.
At his second anger-management session, the class leader asked Loyd not to come back.
"They kicked him out of anger-management counseling through social services because they said he was too angry," Andrea said. "He needed to see someone at mental health. Mental health didn't have an appointment for another month. You can walk in if there's an emergency, but you have to wait with 30 [Advanced Individual Training] students who are there because their drill sergeant yelled at them."
That experience immediately worsened Loyd's condition. He cried for two hours, and then, for the next week, showed no emotion at all. At work and at home, he remained listless, unable to engage in the most basic communication.
"Community Mental Health was ill-equipped to handle the number of soldiers it needed to see," Andrea said.
That surprises no one who has been working with service members returning from war.
"The problem is supply and demand," said Paul Sullivan, executive director of Veterans for Common Sense. "The supply is too low. The demand is very high. As a result, doctors are found to delay or refuse appointments. They hand out prescriptions rather than therapy. They offer group counseling rather than individual counseling."
Sullivan said the problem stems from not enough pay, a hiring process that takes too long and clinicians fleeing the military because of high rates of burnout — the caseloads are too high for people to feel like they're accomplishing anything.
"There is a documented disaster going on with suicides and with PTSD [that] is wreaking havoc on service members and veterans," Sullivan said.
Military officials agree that there is a shortage, and they also link that to high rates of suicide.
"Are we hiring enough?" Ellen Embrey, deputy assistant secretary of defense for force health readiness and protection, said at a recent House defense appropriations panel ahearing. "I don't think we could hire enough at this point. The services had hoped to hire 1,000, and they've hired 800, so they're not as successful as they'd like."
At a House Armed Services Committee hearing about the Army's record suicide rate, Vice Chief of Staff Gen. Peter Chiarelli chalked up the situation up to one major issue: "Counselors — I don't have enough right now."
Erik had also tried to get appointments at Fort Lee for his own symptoms of combat stress.
"They keep saying they're short-staffed," he said. "And people keep resigning. Sometimes I feel like I'm treading water and I'm barely staying afloat."
His symptoms are not as severe as Loyd's — a high startle response and some anger-management issues — but he said he feels like he needs a little help figuring out what's upsetting him and how he can keep his deployment from affecting other areas of his life.
After he freaked out when his wife Robin reorganized their kitchen, melting down when he couldn't find the lid to a Tupperware container, his wife suggested it might be time to talk to someone.
"I felt so good when I came out of that first session," he said.
The counselor "had me do a couple of diaries to figure out what was irking me. I'm the first one to say, 'Hey, go to community mental health. Don't ever think you have to deal with things on your own.' "
That experience, he said, gave him some insight into what might be going on in Loyd's head. Erik could offer his friend a sympathetic ear, but Loyd was still on his own lonely road.
Waiting for the right treatment
Andrea became so desperate that she called the family doctor back home in North Carolina, who prescribed Zoloft until her husband could get proper treatment.
"Some people can work it through in three to six months," Andrea said. "Loyd just wasn't one of those folks."
The Zoloft wasn't enough.
Loyd couldn't carry on a conversation. He couldn't be on base when the guns went off in the morning and in the afternoon.
"He could barely remember his own name," she said. "It was just bad."
In the last week of April, Loyd saw a social worker who determined that he did, in fact, need to see a counselor. Her evaluation continued May 16, and then he had his first appointment with a psychiatrist May 30 — a full three months after he had initially asked for help.
Loyd began going to a PTSD group therapy meeting once a week, beginning June 6. His next individual appointment was June 19, three weeks after his first meeting with a psychiatrist.
Thus far, one-on-one therapy has been the only scientifically proven way to help treat PTSD, though other therapies in conjunction with individual counseling may speed the healing process. Medications have not yet been shown to be effective for PTSD, though they have been shown to help sleeping problems, nightmares and depression.
Doctors also know that the sooner a person with PTSD is treated, the more likely it is that treatment will be effective.
"Everyone got together on Wednesday morning and talked about what they were mad about and who they were going to kill," Loyd said about his PTSD group sessions. "For the first month or two, it was productive to find out there were other people who were having the same problems I was having."
But eventually, he said, it became a "bitch session."
From that point, Loyd had individual counseling sessions about once a month — 15-minute sessions to talk about and adjust his medications, but not about what he had experienced.
His depression increased. His symptoms worsened.
From one diagnosis to another
At first, his therapist diagnosed him with adjustment disorder, which is different in that the stressor is not as intense as it is in cases of PTSD or acute stress.
The Diagnostic and Statistical Manual of Mental Disorders is clear on what qualifies as a stressor for PTSD: "The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others," and the person's response "involved intense fear, helplessness, or horror."
Loyd had experienced both.
Then the same therapist changed his diagnosis to PTSD.
In mid-August, Loyd's therapist again changed his diagnosis, saying he no longer had PTSD. He had a mood disorder.
"I lost a lot of confidence in my mental health care provider," Sawyer said. "I don't have PTSD anymore? I'm cured? Everything's going on just like it was before."
A second counselor, Jim Doran, had been working with Loyd's son Caleb as he tried to adjust to his dad's PTSD. He had Loyd come in a few times with Caleb to try to work through issues together.
Doran sent a note to Loyd's military doctors: "The intensity of Mr. Sawyer's emotions struck me as especially severe in light of my experience treating many military and their dependents and spending a year in training at a VA hospital."
Loyd said he thinks an order came down from on high because several people had their PTSD diagnoses changed to adjustment disorder at the same time.
Then, a month later, Loyd's military therapist changed his diagnosis back to PTSD.
Through November, he went to counseling and group sessions. Through November, he wept on the floor with the dog.
"If I'm not immediately homicidal or ready to blow my brains out, the doctor doesn't want to see me," he told his wife. "I'm not there yet."
Yet. That one word sent Andrea into a panic.
She called the doctor herself the next day. The doctor asked if Sawyer was drinking. Yes, she said, he drinks at night to try to sleep — one or two fifths of liquor. The doctor asked Sawyer to come in, and then cut his antidepressants in half. Sawyer went home and cried for an hour, curled up in the fetal position.
He went to group therapy the next day, a Wednesday. He went home and cried again as Andrea held him. Thursday, a doctor enrolled him in the Army Substance Abuse Program, saying he was an alcoholic. He immediately quit drinking.
"I had tried and tried to scream for help — 'This is not working,' " he said. "Andrea was calling mental health every day. I think that last week, I was not sleeping at all. I was having episodes of drinking heavily, but then I just quit because they said that was the problem.
The last straw
On Monday, Dec. 17, he had an individual appointment, but after another session that focused on his meds, he came home talking like he'd given up. The doctor scheduled his next individual appointment for Jan. 26.
Andrea asked the receptionist, who had seen Sawyer every day that week, if she really thought that was a good idea.
"Be in at 1400 Wednesday," the receptionist responded.
On Wednesday, Andrea said, "Loyd, tell the doctor how you feel."
Loyd, sitting curled up as tightly as he could in the doctor's office chair, bawled as he told the doctor he planned to kill himself the next morning, but that he didn't want to miss Christmas with his boys.
The plan was detailed: He would go to the company area the next morning, stab himself in the throat and bleed out in two minutes, knowing no one would be able to help him.
"My husband had made his plan and made peace with his decision by the time the conversation took place," Andrea recounted. "I had been loudly voicing my concerns to his attending psychiatrist, but he seemed surprised by my husband's intentions."
She said the doctor sat forward on his chair so quickly she thought he was going to fall off.
She remembers the doctor saying: "I didn't know we were there … I didn't think we were that close."
But Andrea knew. She had sent her boys to stay with their grandparents because she was afraid they would come home one night and find their father dead. But she hadn't heard him say it.
"It was horrible," she said. "I have those words engraved in my mind and my heart. No matter how many times I write it or say it, it doesn't hurt any less."
The doctor immediately wrote up the paperwork necessary to admit Sawyer as an inpatient to Portsmouth Naval Medical Center. Erik rushed over to drive the Sawyers to Portsmouth.
"Loyd had this look on his face like he was just done," Erik said. "He looked like hell.
Erik immediately began wondering what he could have done. "I'd been thinking, 'Loyd's got an appointment today, so he's fine," he said. "I thought he was getting the help he needed."
He said he had no idea his friend was near death.
"I almost cried," Erik said. "How close was I to losing a friend? How did I miss the signs?"
The trip to the hospital left Erik sick with worry.
"I'm sorry you got pulled into this," Loyd said as they drove down.
"No reason to be sorry," Erik reassured his battle buddy.
"I love you," Loyd said.
"I know, man," Erik said. "I love you too. You'd do the same damned thing for me."
Loyd's paperwork from Fort Lee said he would be admitted for alcohol abuse. Within 24 hours, the staff at Portsmouth had replaced alcoholism with PTSD resulting in major depression.
"The night that I dropped him off at Portsmouth," Andrea said, "was really the first time I felt he was safe in a long time."