Noteworthy News Articles on Mental Health Topics, August 9-20, 2006

No Therapy for Patients on Antidepressants
Associated Press, 8/9/2006

TRENTON, N.J. -- A huge study found that patients on antidepressants rarely get the psychiatric therapy needed right after they start the drugs, a time when risk of suicidal behavior can rise temporarily. Two-thirds of children and even more adults did not see a doctor or therapist for mental health care once within a month of beginning drug treatment, according to the study by Medco Health Solutions Inc., which manages prescription benefits for health plans. Experts suggest the cost of therapy, a lack of follow-up by busy family doctors, and a shortage of psychiatrists in some parts of the country might help explain the problem.
      Medco's study of 79,488 adults and 5,026 youngsters reviewed prescription and doctor visit records from July 2001 through September 2003. That was before the government urged drug makers to put warnings on their products calling for close monitoring of suicidal thoughts or violent behavior in the early weeks after starting the drugs. ''Many of these people probably should have had more follow-up than they did, regardless of the FDA guidelines,'' said Dr. Glen Stettin of Franklin Lakes-based Medco, which paid for the study.
     In early 2004, the Food and Drug Administration recommended that new antidepressant users see a doctor once a week for the first month and three more times in the following two months. That advice is the agency's ''best estimate'' of what's reasonable, said Dr. Thomas Laughren, director of the Division of Psychiatry Products at the FDA. Laughren said he is concerned that so few people in the study failed to get therapy, but said the sicker patients probably got more help.
     The Medco study also looked at treatment through the first three months and found that more than half the children and three-quarters of adults still had not had a mental health visit. Fewer than 15 percent of patients got all the treatment the FDA recommends in the first month, according to the study, which was published in this month's American Journal of Managed Care.
     More than half of antidepressant prescriptions are written by family doctors, and there are only about 40,000 psychiatrists nationwide. That's one reason some experts believe there is little follow-up care. In addition, Dr. Darrel Regier, the American Psychiatric Association's director of research, said that carrying out the FDA treatment recommendations would push up costs up more than 50 percent.
     Stettin and other doctors said follow-up therapy has probably improved a bit since Medco's study was done because of heavy press attention, particularly about antidepressants and suicide concerns with teenagers. Medco plans an update to see if that's so. Meanwhile, the number of children taking antidepressants dropped 18 percent in the first three months of 2004, an earlier study by Medco found. ''That's something a lot of people are concerned about,'' Laughren said. That's because for many patients, not treating depression is more dangerous than the slight increased risk of suicidal behavior at the onset of treatment -- from 2 percent to 4 percent, according to 24 studies in children reviewed by the FDA. ''Ten percent of patients with severe depression will kill themselves'' without treatment, said Dr. Richard A. Friedman, director of the psychopharmacology clinic at Cornell University's medical school.



What’s Left Unsaid
The Unsayable: The Hidden Language of Trauma.
By Annie G. Rogers; 302 pp. Random House. $25.95.
Kathryn Harrison, New York Times Book Review- 8/13/2006

At the age of 16, Annie Rogers stopped speaking. “I realized,” she explains in her new book, “that whatever I might say could be misconstrued and used to create a version of ‘reality’ that would be unrecognizable, a kind of voice-over of my truths I could not bear.” Given her apprehension, silence was a sane response — the only response possible for a girl who understood herself as having been called by the archangel Michael to end human suffering by translating “the voices of angels for the world.”
     Rogers recovered; she spoke; she grew up and became a Harvard University professor and a clinical psychologist who treated abused and abandoned children, fulfilling the vocation that, when she was a teenager, landed her in a mental institution. She no longer felt the responsibility to convey messages from heaven and had replaced the archangel with another divinity of sorts, someone with a different ecstatic following — Jacques Lacan — but ending human suffering remained her purpose. “The Unsayable: The Hidden Language of Trauma” is an account of Rogers’s successes, as well as her frustrations, in helping girls, herself included, hear the stories of their pasts and discover the truths of their essential selves, truths that surface no matter how forcefully they are repressed. A basic principle of psychoanalysis, Rogers, who now teaches at Hampshire College in Massachusetts, reminds us, is that a powerful, even controlling part of each person, the unconscious, “insists on knowing the truth, even if the truth is a shocking and costly retrospective.”
     She calls her own troubled adolescence “a place of shattering and beginnings,” and she presents her personal history as a prelude to a series of case studies that reveal how the ideas of Lacan (whom she introduces as “enigmatic, maddeningly obscure”) provided her an essential tool for analysis. Those ideas offered Rogers “a structure for listening” to her patients so as to help them understand themselves and transcend symptoms more commonly treated with cognitive-behavioral therapies developed for post-traumatic stress disorder. Lacan’s contention that “the unconscious is structured like a language” was the epiphany — the light-bulb moment — she needed to begin to untangle the puzzles of symptoms, actions and statements that characterized the abused children she worked with, many of whom were considered too sick or damaged to be helped.
     When we contemplate acts we consider unspeakable, we call on a civilized society’s imperative to remain silent about physical abuse, rape, incest — the third monkey in the see-no-evil, hear-no-evil, speak-no-evil triumvirate of denial that protects abusers who hold victims in their thrall. As a matter of conscience we fight to create a climate in which victims are not shamed into silence’s effective complicity. But unspeakable is not the same as unsayable. The first audience of the self is, of course, the self, and what stops us from revealing hurtful and damaging events isn’t (or isn’t only) imposed from without. Before they protect their predators, victims of trauma (defined as any experience “which by its nature is an excess of what we can manage or bear”) protect themselves by not consciously expressing what happened to them. To articulate, or to say, is to put together, to draw fragments of an experience into a coherent narrative, a potentially devastating process if the experience was so overwhelming as to have been, like the author’s own past, “shattering.” Before a thing is consciously (if not audibly) voiced, it has yet to be acknowledged or owned; it has yet to be believed.
     Rogers’s user-friendly (and admittedly self-serving) summary of Lacanian psychoanalytic thought explains that human beings are “born into language,” and that as we acquire language we discover loss. Our preverbal selves are one with an all-providing mother who anticipates needs we cannot give voice to; our verbal selves have separated, enough that we are conscious of that separation. Necessarily, we are traumatized by what separation means: that we must rely on language to express our demands and thus risk being misunderstood. It is equally risky to be understood too well, and in order to get the affirmation we crave from mother, we repress or censor what we imagine she won’t like.
      While Rogers apologizes for having to guide her readers through enough psychoanalytic theory to understand the work she does with damaged children, her abbreviated tutorial helps make “The Unsayable” an absorbing, even exciting book for readers who are neither victims of abuse nor therapists. To grow up and become fully human is traumatic. Whether we recognize it or not, each of us is poised between two existential terrors, that of remaining unknown and unseen, our anguish and our joys without witness, and that of being known so completely that we are left undefended. Every reader of this review has experienced overwhelming and unbearable separation from his or her mother, trauma that fractured each of us into a conscious and an unconscious self.
     Lacan’s insights represent a “radical return to Freud,” to the concept of a separate and dynamic unconscious where “time stands still, words function as puns, forbidden ideas find uncanny disguises and dreams are riddles or puzzles.” The Freudian, or Lacanian, analyst is as much sleuth as listener, piecing together a code that emerges from language, symptoms and actions. “Although unconscious life is anything but random, its logic isn’t always clear” but it can be deciphered “through associations and in retrospect.” In recounting her treatment of an 11-year-old girl who suffered debilitating headaches and anxiety in the wake of being abused by a neighbor, Rogers outlines a process of listening for words or even parts of words the girl repeated during therapy, remarking how motifs from her dreams connected to her waking life, and remaining alert to any physical symptoms, in this case the headaches. After sessions, Rogers took notes, and she ruminated on what she’d heard. Like a good detective, she acted on a hunch as well as evidence when she asked the child if headaches might not be code for Ed aches, a way of “telling by not telling” that the neighbor, whose name was Ed, had hurt her.
     Psychoanalysis has been eclipsed to a great extent by less expensive and less time-consuming ego-based therapies, and by the even shorter cut of psychopharmacology. But as “The Unsayable” demonstrates, analysis is as uniquely rewarding as it is demanding. Given discipline, patience — and a measure of courage — it may be the only means of reaching certain patients. To learn that “the unconscious is structured like a language” is to see this aspect of the self as radically different from the way it is popularly misrepresented, as a murky soup of dream fragments and primitive urges from which it’s possible to fish out the occasional insight, a kind of primordial chaos from which higher consciousness distinguishes itself.
     For Freud, Lacan and Rogers, the unconscious is as complex and sophisticated in its organization as is the conscious, and as individual: each psyche requires its own lexicon. Within this mysterious realm that the Jungian analyst Alan McGlashan called a “savage and beautiful country,” Lacan’s voice does hold the power of an archangel’s, and Rogers’s ability to listen and perceive has an equally rare authority. It isn’t everyone who can hear what we don’t allow ourselves to say.

Obsession Can Make Youngsters Too Body-Conscious
Candice Choi, Associated Press- 8/13/2006

Mom's dieting habits can have a bad influence on the children. Some research indicates youngsters learn attitudes about dieting through observation. For some youngsters, that might mean an unhealthy fixation on body image, experts warn. "It's like trying on Mom's high heels. They're trying on their diets, too," said Carolyn Costin, spokeswoman for the National Eating Disorder Association.
     As obesity rates climb among children, health officials are warning parents about the dangers of junk food and lack of exercise. Yet few speak about parents who meticulously count every calorie that crosses their lips. That type of obsession can be just as destructive and eventually teaches kids to weigh their self-worth on the scale, said Christine Gerbstadt, spokeswoman for the American Dietetic Association. .
     While fathers also play a crucial a role in shaping children's attitudes about food, research has focused primarily on women and their daughters, since females are more likely to diet and worry about body image. One study published last year by researchers at Harvard Medical School found that frequent dieting by mothers was associated with frequent dieting by their adolescent daughters. The study also found that girls with mothers who had weight concerns were more likely to develop anxieties about their own bodies.
     A study in the Journal of the American Dietetic Association found that 5-year-old girls whose mothers dieted were twice as likely to be aware of dieting and weight-loss strategies, as girls whose mothers didn't diet "If their mothers diet, it's a marker of how important weight is in the household," said Alison Field, lead author of the Harvard study and an assistant professor of pediatrics. Even small cues -- such as making self-deprecating remarks about bulging thighs or squealing in delight over a few lost pounds -- can send the message that thinness is to be prized above all else, Field said. "Parents, especially moms, need to understand kids watch and hear things at an early age and are like little sponges," Costin said.
     Walking the line between encouraging healthy habits and not making an issue of weight can be tough, especially with parents already bearing the blame for rising obesity rates among children.
The best strategy is to lead by example, Costin said: If a fad diet isn't right for the child, what makes it right for the parent?
     One Albany, N.Y., mom, Donna Choiniere, does just that. She threw dieting out the window long ago and has made fitness a part of family life. The 52-year-old runs marathons, and her 15 year-old daughter, Katelyn, is on the track team. She tries not to keep heavy-duty junk food in the house, but does not make a big deal about it, and is OK with things like pretzels and popcorn.

The Dollars and Cents of a DUI
Amalie Nash, Ann Arbor News- 8/16/2006

Jason Pasinetti of Ann Arbor fits the demographic profile that authorities hope to reach: between the ages of 21 and 34 and male. When he considers the consequences of drunken driving, he ranks them in this order:
1. The possibility of killing an innocent person or himself.
2. The legal ramifications of court hearings and possible jail time.
3. The costs involved.
      The Michigan Office of Highway Safety Planning hopes more men his age will be swayed by No. 3. In a campaign that starts today, authorities will attempt to deter drunken drivers with increased patrol efforts boosted by TV spots that focus on the financial burden of a drunken-driving arrest. "Any way we can get the message out about the seriousness of the crime of drunk driving, it's a good thing,'' Washtenaw County Sheriff's Cmdr. Dave Egeler said. "I think the financial impact is a strong message.''
     In Washtenaw County, 1,151 motorists were arrested for drunken driving last year. Another 77 were arrested on alcohol-related offenses, like impaired driving and underage drinking and driving. Drunken-driving arrests totaled 805 in Livingston County last year, with an added 50 alcohol-related driving arrests.
     The 2005 Michigan Annual Drunk Driving Audit showed that alcohol was involved in 44 percent of fatal crashes in both counties. There were 32 fatal crashes in Washtenaw and 16 in Livingston. Washtenaw County was below the state average for alcohol-involved crashes, with 12.08 crashes per 10,000 residents in 2005. The statewide average was 13.39; Livingston County was above that average at 13.5.
     The statewide drunken-driving crackdown begins Friday and ends Sept. 4. The television ads will run for three weeks in several markets, including Detroit. One ad focuses on enforcement, noting that 50,000 motorists were arrested for drunken driving in Michigan last year, and the second shows someone dealing with the financial burden of a drunken-driving conviction. A focus group of men ages 21 to 34 indicated that they were most concerned about the financial impacts when drunken driving was discussed, officials said.
     Daniel Geherin, an Ann Arbor defense attorney, said a standard first-offense operating-while-intoxicated charge can carry $1,000 in fines and court costs and $2,000 in driver responsibility fees associated with getting a driver's license reinstated. Attorney fees can run $1,000 to $5,000, and auto insurance rates also are likely to rise, Geherin said.
     Jason Pasinetti, 28, who works for the University of Michigan, said that beyond court and attorney costs, he would be concerned about whether an arrest could affect his job. Still, he said the safety of other motorists and possible incarceration influence his decision the most. "Overall, I don't think some personal decision I would make like drinking and driving should affect the life of another person who had no vote in that,'' said Pasinetti, who has never been arrested but said he knows others who have faced drunken-driving charges. "I'm a little skeptical of a campaign that talks about the monetary costs because some people might calculate those and decide it's worth a risk. In my opinion, saying that the action could be murder sinks in more than the fines.''
     Pasinetti said an effective TV ad for him would show a real person in the same demographic who drove drunk and killed someone, discussing how that changed his life. He also advocated placing portable breath tests at bars and elsewhere that would allow people to clearly see they are not in a condition to drive. "I don't think people understand what level they're at, even if they are trying to calculate it in their head, and their judgment is impaired,'' Pasinetti said. "Some people might think that if they just wait an hour, eat some fries, drink water and walk around the block, they'll be OK. But this would be more clear cut than how they feel, and they would know not to drive.''
     Police agencies across Washtenaw County are participating in the drunken-driving enforcement, which is funded through state office of highway safety planning grants. Egeler said the recent drunken-driving audits support historical data that show alcohol was involved in 30 percent to 50 percent of fatal crashes in the county. He said the reduction in drunken-driving arrests is hard to explain. "It could mean police agencies are busier and have less time to do proactive patrols or, hopefully, it means that the anti-drunk-driving campaigns are having an affect,'' Egeler said.
     State Police Sgt. Tony Cuevas said many of the alcohol-related fatal crashes are single-car accidents that occur on secondary roads. He is an advocate of increased enforcement - and letting motorists know when it's happening. "It's good when it raises the level of awareness, and people heed that message,'' Cuevas said.

Survey Finds Parents in 'Denial' on Teens' Risks
Lois Romano, Washington Post- 8/18/2006

A third of American teenagers have attended parties where parents were at home while alcohol or illegal drugs were used, according to an annual back-to-school survey on teens' attitudes that paints an overall portrait of a generation of parents clueless about their kids' vices. The study did not suggest that parents were aware of what was happening when teenagers were partying in their homes. To the contrary, only 12 percent of parents see drugs and alcohol as a problem for their children, while 27 percent of teenagers ranked it their biggest concern. Fifty-eight percent of parents cited social pressure as their child's biggest issue.
      "These parents are like the three monkeys," said Joseph A. Califano Jr., chairman and president of the National Center on Addiction and Substance Abuse (CASA) at Columbia University. "They see no beer, smell no pot and don't hear all hell breaking loose in the family room because of the alcohol and drugs. . . . It doesn't take a sharp nose to smell pot." "These parents don't understand the world their children are living in," he added. "There is a lot of denial here."
     CASA -- which studies risk factors for substance abuse -- took a particularly close look at parents this year and delved into the private party scene, where much of the underage drinking and drug abuse is thought to occur. In a number of areas, the opinions of the parents were strikingly at odds with the views of their children.
     The study found that 80 percent of parents think that neither alcohol nor marijuana is usually available at parties that their teenagers attend. Fifty percent of teenagers said they had been at parties where alcohol and drugs were being used . For the first time, the CASA survey also found that the substance-abuse gender gap has closed, with girls 12 to 17 at equal or higher risk compared with boys .
     Depending on their responses, the teenagers were categorized as low-risk, moderate-risk or high-risk. The survey showed broad teenage exposure to alcohol, various drugs including cocaine and heroin, and violence. By age 17, one in four teenagers will have known someone who was a victim of gun violence. Among the "high-risk" group, almost two-thirds said they could buy marijuana in an hour or less, 93 percent said they had a friend who uses marijuana, 58 percent reported getting drunk at least once a month, and 71 percent said they had a friend who uses cocaine, LSD or heroin.
     The survey also revealed that the transition stage at 13 and 14 years old is a particularly vulnerable time for teenagers as they enter high school and attain the freedom that comes with it. Fourteen-year-olds were three times as likely to be offered the drug ecstasy, and twice as likely to be offered cocaine, as teenagers a year younger.
     Family structure also showed up as a strong indicator of substance-abuse risk. Teenagers who regularly ate dinner with their families and attended church services were at less risk, as were teenagers who slept more than eight hours a day.
     QEV Analytics, which conducted the survey for CASA, started with a random national sample of 582 parents and 1,297 teenagers, defined for this study as kids 12 to 17. QEV oversampled some demographic groups to ensure a balanced representation of African Americans and Hispanics.
     Califano said that white, black and Hispanic teens experiment with drugs to the same degree and that "poor kids are more likely to get hooked and less likely to get serious treatment."

Thousands of Iraq Veterans Coping With Post-Traumatic Stress
Donna St. George, Washington Post- 8/20/2006

There are times when Trinette Johnson's life seems to stall, when she finds herself staring at the ceiling fan in her bedroom, watching the blades spin, her mind hung on nothing -- not her receptionist job, not her fiance, not her ailing father or her four children. Not even the war. The war, of course, is always there somewhere, she said, an unseen force in her life, sometimes producing moments of blank detachment, sometimes stirring up anger like nothing she has ever known.
      More than two years after returning from duty in Iraq, she has found herself yelling and cursing at other drivers on the road. Panicked in crowds. Seized with fear at the sight of highway overpasses and tunnels that might suddenly explode. Doctors gave the 32-year-old Johnson, who served in the D.C. National Guard, a diagnosis of post-traumatic stress disorder, which has plagued thousands of U.S. troops after combat in Iraq -- bringing on flashbacks, numbness, rage and anxiety and leaving many at odds with their old lives, families and jobs.
     How women are affected after combat is only starting to be probed. This is the first war in which so many women have been so exposed to hostile fire, working a wider-than-ever array of jobs, for long deployments. "This is a really unique experience, and we just don't know," said Ronald C. Kessler, a Harvard University professor and author of a landmark study of post-traumatic stress disorder.
     For women who are mothers, combat-related PTSD may have added significance. Often, after war, "it's not the same mommy who left," said Yale University associate professor Laurie Harkness, who runs a Veterans Affairs mental health clinic in Connecticut. Although the same can be said for fathers, she said, "mothers in general are the emotional hub of a family."
     For Johnson, it was a doctor at Walter Reed Army Medical Center who first uttered the letters P-T-S-D, a defining moment that came after she spent nine months working the bomb-blasted roads near Baghdad. Her job with the 547th Transportation Company was hauling -- troops, supplies, equipment -- and security. At one point, she helped transport dead Iraqis to their wailing relatives. In one particularly bad period, a roadside bomb claimed the life of a 21-year-old soldier in her unit, Spec. Darryl T. Dent. Later, another bomb severely wounded Johnson's best friend, Spec. Antoinette Scott, a mother of four.
     That fall in 2003, Johnson was riding in a truck with her M-16 rifle pointed out the passenger-side window. Out of nowhere came a deafening blast. Her five-ton vehicle swerved and nearly flipped. There was fire. White smoke. Flying debris. A bomb, hidden along a guardrail, had detonated. Johnson received a Purple Heart for hearing loss in her left ear but stayed in Iraq for several more months, working the same roads. "It seemed like once every other or three days somebody was getting hit," she recalled recently. But the enemy was elusive. She never fired her M-16.
     Unexpectedly, in January 2004, she was shipped home three months early, sidelined with severe kidney stones. Later, at Walter Reed, the dreams started: violent dreams, with exploding mortars and hordes of barking dogs. She mentioned them to a doctor. This was while she was living on the hospital grounds, seeing specialists and worrying about whether anyone in her unit had been injured or killed. She called her unit in Iraq every day. But she had not seen her kids.
     A counselor prodded her to visit them -- three were being cared for by Johnson's sister in Falls Church, and one was in Richmond with the child's paternal grandmother. None of the children lived with their fathers. "Mommy! Mommy!" her youngest daughter, then 2, shrieked during a visit in Falls Church, climbing all over her. Johnson had been a mother since she had her son at age 14. Now she felt overwhelmed. She rose to leave. "I can't do this," she told her sister. In her car, she sobbed, wondering how she could feel so disconnected. "I realized that I just walked out on my babies."

* * *

In nearly 3 1/2 years of war, more than 137,000 female troops have served in Iraq and Afghanistan, some exposed to the most profound stresses of combat: ambushes, mortars, bombs, fallen comrades. They have fired M-16s and grenade launchers, killed people and been shot at.
      As these women have returned home, Army researchers studying the psychological fallout of Iraq have noted a surprising trend in early studies: Women appear to be showing symptoms of post-traumatic stress disorder and other mental health troubles at roughly the same rates as men. If this result holds true, it would stand out because women studied in the overall population show markedly higher rates of post-traumatic stress disorder than men -- about twice as much. "It's not definitive, but it's encouraging," said Patricia A. Resick, director of the Women's Health Sciences Division of the National Center for PTSD, part of the Veterans Affairs Department. Resick said more research is needed.
     While studies of the war's effects continue, one fact is clear: A generation of U.S. military women is at risk of combat-related stress disorder as never before. A recent study showed that, overall, more than one in three U.S. troops sought mental-health care in the year after returning from Iraq. An earlier study found that about one in six showed signs of PTSD, major depression or anxiety after Iraq. "From our data, what it looks like is that women serving in combat have the same risk as men of getting PTSD or other mental health conditions," said Charles W. Hoge of the Walter Reed Army Institute of Research.
     For Johnson, treatment at Walter Reed made things better, with group sessions, art therapy and combat-stress counseling. "You're in there with other people who are going through the same things," she said, "and you kind of feel like, 'Okay, now I don't feel crazy.' " The most wrenching day, as she remembers it, was when she was sent home: Oct. 3, 2004. No longer did she have the supportive environment of the hospital. She was on her own, medically discharged from the military because of the stress disorder. Outwardly, Johnson looked much the same: bright eyes peering through delicate glasses, big smile, always seeming on the verge of a laugh. "Dee," everyone called her. But much had changed. "I don't even know this life," she said one day.
     For several months, while her fiance supported them, she could not bring herself to go to work. Finally, last year, she returned to her job as a receptionist in the National Guard building in Northwest Washington, which houses a museum lined with exhibits that depict combat. The images did not bother her. The hard thing was that in the life she returned to, almost no one seemed to understand Iraq. They did not know what it was like to live with hidden enemies and fatal explosions, to feel so far from family and become so attached to other soldiers. Some people told her: "I couldn't have left my kids like that."
      The comments upset her because they implied a choice she did not have. She was a National Guard soldier, a job she took in 1997 as a steppingstone to more financial stability at a time when she was a single mother of three. The Iraq war did not seem a possibility then. Her father had served 26 years as a guardsman without seeing battle. In 2003, Johnson left for war as her youngest was learning to talk.

     Johnson understands the danger of alcohol partly from her fiance, Mark Branch, who was her battle buddy in Iraq. He was driving the five-ton truck the day the bomb went off along the guardrail. After Iraq, he drank so much Rémy Martin cognac that she lined up all of his empty liquor-bottle boxes along the top of their kitchen cabinets. "How many fifths did I go through?" he asked her one day as they thought back. He checked into a treatment program at Walter Reed, too.
     The way Branch sees it, "a lot of us, we come back, and we have to go back to work because we have families, we have jobs, we have houses." Finding time to pursue counseling seemed impossible. "You're never going to be healed from it," he said. "They just teach you how to live with it."
     In her own life, Johnson finds herself off balance in ways that have surprised her. One day she banged up her car but could not recall how. She heard the smack, yes. But how did she get up on the curb? Did she swipe a fire hydrant? "It's almost like I'm there but I'm not there sometimes," she said. Another day, she recalled, it was the usual Washington traffic as she drove her Chrysler Concorde with the Purple Heart license plates. Along a snarled street, a bus driver blared his horn at her. She yelled, cursed, then hurled an empty Coke cup at the bus before she even knew what she was doing. "You don't realize what you're doing until after, or sometimes a lot after," she said, later reflecting: "My temper is on a whole other level."
     Then there was the time she got stuck in traffic near a highway overpass in Prince George's County. In Iraq, overpasses could conceal bombs. She felt a crushing sense of danger -- and traffic was at a dead stop. "I was just losing it," she recalled. In hysterics, Johnson phoned her fiance, who told her: Put the car in park and walk away until you settle down. When the traffic starts to move, climb back in your car.
     More than 2 1/2 years after her return from war, her sense of safety has not returned. She worries as never before about terrorist attacks and suicide bombers. "I always make sure I'm armed, regardless," she said, mentioning a knife she keeps around. "I always make sure I have something to defend myself."
     She has had a hard time with the VA. She applied for disability compensation, but it took 14 months, and there are still problems. She started mental health sessions but wound up disappointed. She said the VA canceled her appointment in October. In November. In December. Each time, there was a different reason, she said. Her therapist was sick. Her name was not on the schedule. All of that, she said, has added to her stress. "I haven't been there in four months, and they haven't even noticed," Johnson said early this year. VA officials declined to discuss her case but said that, overall, veterans get the PTSD care they need.
     In February, Johnson said, her social worker made some calls and got her a 30-minute session March 8. But problems at work so consumed her that she could not remember what to tell the doctor. Usually, she makes a list of things to bring up. Once, she asked: How long am I going to be like this? "It could stop today, or it could go on for years," she said she was told, which brings her to this: "That's what scares me. I just get scared that I'll be one of those homeless people that you see holding the signs because I've lost my mind."
     For now, her fate is nothing like that. She and her fiance bought a house this year, a brick rancher with a big back yard in Clinton. Her children seem happier, planted. Her eldest daughter is 14, an honor student and soccer-team captain. Her youngest, now 5, is still focused on Mommy, and Johnson is glad -- though sometimes she still finds herself overwhelmed. On weekends, she and her fiance often have six or more children around, hers and his and often a niece or nephew.
     After Iraq, she rarely goes out anymore -- not to clubs, not to movies. She passed up a chance to apply for a higher-paying job in her office because she felt she could not manage additional pressure. Some days, she feels perilously close to the edge. If she is home, she may retreat to her bedroom. There, she can collect herself. Or she may, for a moment, lose her connection to everything, as the ceiling fan turns, as her mind goes blank. Her eldest daughter was nearly 12 when Johnson returned. The girl seemed different -- dressing in black, skipping school, no more smiles, no hugs. She wondered: Was it because of her absence? She recalled, "I'm looking and I'm trying to figure out, 'Where is my child?' "

* * *

Even now, there are times Johnson feels uncomfortable talking about post-traumatic stress disorder. It's an invisible wound in a war with daily bloodshed. At Walter Reed, she said, she saw soldiers with missing arms or legs, paralysis, shrapnel scars. She is not so physically injured. Still, her diagnosis scares her.
      It took her six months after she left Walter Reed to make herself go to a VA office and stay for an appointment. She put it off at first, then became overwhelmed by the sight: veterans with glazed looks, some seeming at loose ends with nothing else to do. "I would see some of the older vets sitting there," she recalled, "and I would be like, 'Lord, have mercy. I do not want that to be me.' "
     She gave up alcohol. Some veterans drink a lot, she said, and she does not want to "self-medicate," as she called it. "It doesn't make Iraq go away," she said. "But obviously, if you pass out, then there's nothing bothering you at that time." Johnson understands the danger of alcohol partly from her fiance, Mark Branch, who was her battle buddy in Iraq. He was driving the five-ton truck the day the bomb went off along the guardrail.
     After Iraq, she rarely goes out anymore -- not to clubs, not to movies. She passed up a chance to apply for a higher-paying job in her office because she felt she could not manage additional pressure. Some days, she feels perilously close to the edge. If she is home, she may retreat to her bedroom. There, she can collect herself. Or she may, for a moment, lose her connection to everything, as the ceiling fan turns, as her mind goes blank.