Noteworthy News Articles on Mental Health Topics, January 14-20, 2008



Drug Approved. Is The Disease Real?
Alex Berenson, New York Times- 1/14/2008

Fibromyalgia is a real disease. Or so says Pfizer in a new television advertising campaign for Lyrica, the first medicine approved to treat the pain condition, whose very existence is questioned by some doctors. For patient advocacy groups and doctors who specialize in fibromyalgia, the Lyrica approval is a milestone. They say they hope Lyrica and two other drugs that may be approved this year will legitimize fibromyalgia, just as Prozac brought depression into the mainstream. But other doctors — including the one who wrote the 1990 paper that defined fibromyalgia but who has since changed his mind — say that the disease does not exist and that Lyrica and the other drugs will be taken by millions of people who do not need them.
     As diagnosed, fibromyalgia primarily affects middle-aged women and is characterized by chronic, widespread pain of unknown origin. Many of its sufferers are afflicted by other similarly nebulous conditions, like irritable bowel syndrome. Because fibromyalgia patients typically do not respond to conventional painkillers like aspirin, drug makers are focusing on medicines like Lyrica that affect the brain and the perception of pain.
     Advocacy groups and doctors who treat fibromyalgia estimate that 2 to 4 percent of adult Americans, as many as 10 million people, suffer from the disorder. Those figures are sharply disputed by those doctors who do not consider fibromyalgia a medically recognizable illness and who say that diagnosing the condition actually worsens suffering by causing patients to obsess over aches that other people simply tolerate. Further, they warn that Lyrica’s side effects, which include severe weight gain, dizziness and edema, are very real, even if fibromyalgia is not.
     Despite the controversy, the American College of Rheumatology, the Food and Drug Administration and insurers recognize fibromyalgia as a diagnosable disease. And drug companies are aggressively pursuing fibromyalgia treatments, seeing the potential for a major new market. Hoping to follow Pfizer’s lead, two other big drug companies, Eli Lilly and Forest Laboratories, have asked the F.D.A. to let them market drugs for fibromyalgia. Approval for both is likely later this year, analysts say.
     Worldwide sales of Lyrica, which is also used to treat diabetic nerve pain and seizures and which received F.D.A. approval in June for fibromyalgia, reached $1.8 billion in 2007, up 50 percent from 2006. Analysts predict sales will rise an additional 30 percent this year, helped by consumer advertising. In November, Pfizer began a television ad campaign for Lyrica that features a middle-aged woman who appears to be reading from her diary. “Today I struggled with my fibromyalgia; I had pain all over,” she says, before turning to the camera and adding, “Fibromyalgia is a real, widespread pain condition.”
     Doctors who specialize in treating fibromyalgia say that the disorder is undertreated and that its sufferers have been stigmatized as chronic complainers. The new drugs will encourage doctors to treat fibromyalgia patients, said Dr. Dan Clauw, a professor of medicine at the University of Michigan who has consulted with Pfizer, Lilly and Forest. “What’s going to happen with fibromyalgia is going to be the exact thing that happened to depression with Prozac,” Dr. Clauw said. “These are legitimate problems that need treatments.” Dr. Clauw said that brain scans of people who have fibromyalgia reveal differences in the way they process pain, although the doctors acknowledge that they cannot determine who will report having fibromyalgia by looking at a scan.
     Lynne Matallana, president of the National Fibromyalgia Association, a patients’ advocacy group that receives some of its financing from drug companies, said the new drugs would help people accept the existence of fibromyalgia. “The day that the F.D.A. approved a drug and we had a public service announcement, my pain became real to people,” Ms. Matallana said. Ms. Matallana said she had suffered from fibromyalgia since 1993. At one point, the pain kept her bedridden for two years, she said. Today she still has pain, but a mix of drug and nondrug treatments — as well as support from her family and her desire to run the National Fibromyalgia Association — has enabled her to improve her health, she said. She declined to say whether she takes Lyrica. “I just got to a point where I felt, I have pain but I’m going to have to figure out how to live with it,” she said. “I absolutely still have fibromyalgia.”
     But doctors who are skeptical of fibromyalgia say vague complaints of chronic pain do not add up to a disease. No biological tests exist to diagnose fibromyalgia, and the condition cannot be linked to any environmental or biological causes. The diagnosis of fibromyalgia itself worsens the condition by encouraging people to think of themselves as sick and catalog their pain, said Dr. Nortin Hadler, a rheumatologist and professor of medicine at the University of North Carolina who has written extensively about fibromyalgia. “These people live under a cloud,” he said. “And the more they seem to be around the medical establishment, the sicker they get.”
     Dr. Frederick Wolfe, the director of the National Databank for Rheumatic Diseases and the lead author of the 1990 paper that first defined the diagnostic guidelines for fibromyalgia, says he has become cynical and discouraged about the diagnosis. He now considers the condition a physical response to stress, depression, and economic and social anxiety. “Some of us in those days thought that we had actually identified a disease, which this clearly is not,” Dr. Wolfe said. “To make people ill, to give them an illness, was the wrong thing.”
     In general, fibromyalgia patients complain not just of chronic pain but of many other symptoms, Dr. Wolfe said. A survey of 2,500 fibromyalgia patients published in 2007 by the National Fibromyalgia Association indicated that 63 percent reported suffering from back pain, 40 percent from chronic fatigue syndrome, and 30 percent from ringing in the ears, among other conditions. Many also reported that fibromyalgia interfered with their daily lives, with activities like walking or climbing stairs. Most people “manage to get through life with some vicissitudes, but we adapt,” said Dr. George Ehrlich, a rheumatologist and an adjunct professor at the University of Pennsylvania. “People with fibromyalgia do not adapt.”
      Both sides agree that people who are identified as having fibromyalgia do not get much relief from traditional pain medicines, whether anti-inflammatory drugs like ibuprofen — sold as Advil, among other brands — or prescription opiates like Vicodin. So drug companies have sought other ways to reduce pain.
     Pfizer’s Lyrica, known generically as pregabalin, binds to receptors in the brain and spinal cord and seems to reduce activity in the central nervous system. Exactly why and how Lyrica reduces pain is unclear. In clinical trials, patients taking the drug reported that their pain — whether from fibromyalgia, shingles or diabetic nerve damage — fell on average about 2 points on a 10-point scale, compared with 1 point for patients taking a placebo. About 30 percent of patients said their pain fell by at least half, compared with 15 percent taking placebos. The F.D.A. reviewers who initially examined Pfizer’s application for Lyrica in 2004 for diabetic nerve pain found those results unimpressive, especially in comparison to Lyrica’s side effects. The reviewers recommended against approving the drug, citing its side effects.
     In many patients, Lyrica causes weight gain and edema, or swelling, as well as dizziness and sleepiness. In 12-week trials, 9 percent of patients saw their weight rise more than 7 percent, and the weight gain appeared to continue over time. The potential for weight gain is a special concern because many fibromyalgia patients are already overweight: the average fibromyalgia patient in the 2007 survey reported weighing 180 pounds and standing 5 feet 4 inches. But senior F.D.A. officials overruled the initial reviewers, noting that severe pain can be incapacitating. “While pregabalin does present a number of concerns related to its potential for toxicity, the overall risk-to-benefit ratio supports the approval of this product,” Dr. Bob Rappaport, the director of the F.D.A. division reviewing the drug, wrote in June 2004.
     Pfizer began selling Lyrica in the United States in 2005. The next year the company asked for F.D.A. approval to market the drug as a fibromyalgia treatment. The F.D.A. granted that request in June 2007. Pfizer has steadily ramped up consumer advertising of Lyrica. During the first nine months of 2007, it spent $46 million on ads, compared with $33 million in 2006, according to TNS Media Intelligence.
     Dr. Steve Romano, a psychiatrist and a Pfizer vice president who oversees Lyrica, says the company expects that Lyrica will be prescribed for fibromyalgia both by specialists like neurologists and by primary care doctors. As doctors see that the drug helps control pain, they will be more willing to use it, he said. “When you help physicians to recognize the condition and you give them treatments that are well tolerated, you overcome their reluctance,” he said.
     Both the Lilly and Forest drugs being proposed for fibromyalgia were originally developed as antidepressants, and both work by increasing levels of serotonin and norepinephrine, brain transmitters that affect mood. The Lilly drug, Cymbalta, is already available in the United States, while the Forest drug, milnacipran, is sold in many countries, though not the United States. Dr. Amy Chappell, a medical fellow at Lilly, said that even though Cymbalta is an antidepressant, its effects on fibromyalgia pain are independent of its antidepressant effects. In clinical trials, she said, even fibromyalgia patients who are not depressed report relief from their pain on Cymbalta. The overall efficacy of Cymbalta and milnacipran is similar to that of Lyrica. Analysts and the companies expect that the drugs will probably be used together. “There’s definitely room for several drugs,” Dr. Chappell said.
     But physicians who are opposed to the fibromyalgia diagnosis say the new drugs will probably do little for patients. Over time, fibromyalgia patients tend to cycle among many different painkillers, sleep medicines and antidepressants, using each for a while until its benefit fades, Dr. Wolfe said. “The fundamental problem is that the improvement that you see, which is not really great in clinical trials, is not maintained,” Dr. Wolfe said. Still, Dr. Wolfe expects the drugs will be widely used. The companies, he said, are “going to make a fortune.”



Mid-Life Crisis? Maybe He’s a Narcissistic Jerk
Richard Friedman, M.D., New York Times- 1/15/2008

With the possible exception of “the dog ate my homework,” there is no handier excuse for human misbehavior than the midlife crisis. Popularly viewed as a unique developmental birthright of the human species, it supposedly strikes when most of us have finally figured ourselves out — only to discover that we have lost our youth and mortality is on the horizon. No doubt about it, life in the middle ages can be challenging. (Full disclosure: I’m 51.) What with the first signs of physical decline and the questions and doubts about one’s personal and professional accomplishments, it is a wonder that most of us survive.
      Not everyone is so lucky; some find themselves seized by a seemingly irresistible impulse to do something dramatic, even foolish. Everything, it appears, is fair game for a midlife crisis: one’s job, spouse, lover — you name it. I recently heard about a severe case from a patient whose husband of nearly 30 years abruptly told her that he “felt stalled and not self-actualized” and began his search for self-knowledge in the arms of another woman. It was not that her husband no longer loved her, she said he told her; he just did not find the relationship exciting anymore. “Maybe it’s a midlife crisis,” she said, then added derisively, “Whatever that is.”
     Outraged and curious, she followed him one afternoon and was shocked to discover that her husband’s girlfriend was essentially a younger clone of herself, right down to her haircut and her taste in clothes. It doesn’t take a psychoanalyst to see that her husband wanted to turn back the clock and start over. But this hardly deserves the dignity of a label like “midlife crisis.” It sounds more like a search for novelty and thrill than for self-knowledge.
     In fact, the more I learned about her husband, it became clear that he had always been a self-centered guy who fretted about his lost vigor and was acutely sensitive to disappointment. This was a garden-variety case of a middle-aged narcissist grappling with the biggest insult he had ever faced: getting older. But you have to admit that “I’m having a midlife crisis” sounds a lot better than “I’m a narcissistic jerk having a meltdown.”
     Another patient, a 49-year-old man at the pinnacle of his legal career, started an affair with an office colleague. “I love my wife,” he said, “and I don’t know what possessed me.” It didn’t take long to find out. The first five years of his marriage were exciting. “It was like we were dating all the time,” he recalled wistfully. But once they had a child, he felt an unwelcome sense of drudgery and responsibility creep into his life. Being middle-aged had nothing to do with his predicament; it was just that it took him 49 years to reach a situation where he had to seriously take account of someone else’s needs, namely those of his baby son. In all likelihood, the same thing would have happened if he had become a father at 25.
     Why do we have to label a common reaction of the male species to one of life’s challenges — the boredom of the routine — as a crisis? True, men are generally more novelty-seeking than women, but they certainly can decide what they do with their impulses. But surely someone has had a genuine midlife crisis. After all, don’t people routinely struggle with questions like “What can I expect from the rest of my life?” or “Is this all there is?” Of course. But it turns out that only a distinct minority think it constitutes a crisis. In 1999, the MacArthur Foundation study on midlife development surveyed 8,000 Americans ages 25 to 74. While everyone recognized the term “midlife crisis,” only 23 percent of subjects reported having one. And only 8 percent viewed their crisis as something tied to the realization that they were aging; the remaining 15 percent felt the crisis resulted from specific life events. Strikingly, most people also reported an increased sense of well-being and contentment in middle age.
     So what keeps the myth of the midlife crisis alive? The main culprit, I think, is our youth-obsessed culture, which makes a virtue of the relentless pursuit of self-renewal. The news media abound with stories of people who seek to recapture their youth simply by shedding their spouses, quitting their jobs or leaving their families. Who can resist? Most middle-aged people, it turns out, if we are to believe the definitive survey. Except, of course, for the few — mainly men, it seems — who find the midlife crisis a socially acceptable shorthand for what you do when you suddenly wake up and discover that you’re not 20 anymore.

'Lobotomist' Serves as a Warning
Sandra Boodman, Washington Post- 1/15/2007

One of the most horrifying medical treatments of the 20th century was carried out not clandestinely, but with the approval of the medical establishment, the media and the public. Known as the transorbital or "ice pick" lobotomy, the crude and destructive brain-scrambling operation performed on thousands of psychiatric patients between the 1930s and 1960s was touted as a cure for mental illness.
      Its prosaic name comes from the instrument initially used to perform it: an ice pick plucked from the kitchen drawer of the procedure's tireless proselytizer, Walter J. Freeman, who pioneered the operation in 1936 while at George Washington University Hospital.
     The story of how Freeman sold his procedure to credulous colleagues, assiduously courted the press and convinced desperate families that sticking an ice pick through a patient's upper eye sockets and twirling it like a swizzle stick through brain matter would cure psychosis, depression or troublesome behavior is the ultimate in cautionary medical tales.
     As the riveting hour-long "American Experience" documentary "The Lobotomist" (scheduled to air Jan. 21 at 9 p.m. on WETA and other PBS stations) makes clear, Freeman's operation reflected the neurologist's peculiar combination of zealotry, talent, hubris and, as one of his trainees noted, craziness. Sometimes Freeman, who relished putting on a show, used a carpenter's mallet instead of a surgical hammer during demonstrations of his operation. At other times, he would operate left-handed rather than right-handed.
     Based in part on the much-praised 2005 biography "The Lobotomist" by medical writer Jack El-Hai, who appears in the film and served as a consultant, the film by Barak Goodman and John Maggio features chilling black-and-white home movies as well as haunting photographs of patients before and sometimes after their lobotomies. Many of the movies are narrated by a gravel-voiced Freeman demonstrating the procedure he performed on more than 2,900 people, the youngest of whom was 4.
     As the filmmakers note, lobotomy flourished in a therapeutic vacuum: Until the mid-1950s when the groundbreaking tranquilizer Thorazine swept through mental hospitals, ushering in the era of psychopharmacology, medicine had virtually nothing to offer psychiatric patients. State hospitals were teeming, squalid warehouses that had become permanent homes to thousands who had little hope of ever leaving. One of the most notorious was Washington's St. Elizabeths Hospital, where Freeman began his career in the 1920s and was struck by the sight of 5,000 patients "whose lives were going nowhere, would go nowhere," in the words of El-Hai.
     The solution, Freeman believed, lay in a radical experimental procedure invented by a Portuguese neurologist who in 1949 would win the Nobel Prize in medicine. He claimed the drastic brain operation had cured a substantial number of people with mental illness.
     The scion of a distinguished Philadelphia medical family who had a burning desire for fame, Freeman began experimenting and developed the ice pick procedure. His operation severed the frontal lobe from the thalamus, the repository of emotions and the site where Freeman believed mental illness originated.
     A few patients and their families claimed lobotomy was beneficial, especially in reducing agitation, which was Freeman's measure of success. But others died on the table or were left irreparably damaged: childlike, docile, vacant and incontinent. Among them was Rosemary Kennedy, the 23-year-old mildly retarded sister of John F. Kennedy, who spent 56 years of her life in an institution after Freeman operated on her in 1941.
     Undaunted by his failures, Freeman's pitch that lobotomy cured mental illness was seized on by the press -- the Washington Star called it among "the greatest innovations of this generation," and the New York Times pronounced it "history-making." Many doctors embraced it as a 10-minute operation that promised to empty mental hospitals and return patients to their families. Opponents, mostly psychiatrists who practiced Freudian talk therapy, didn't matter much: In those days public criticism of a doctor by his peers was regarded as unethical.
     By the early 1960s lobotomy had fallen out of favor, in part because of its low success rate and the disastrous harm it inflicted on many patients. Freeman, who died in 1972, performed his last lobotomy in 1967; his privileges at Herrick Hospital in Calif., were revoked after the patient died.
     While several of his relatives appear on camera, one of the most affecting interviews is with Berkeley bus driver Howard Dully, who was lobotomized by Freeman at age 12 after his stepmother complained he was difficult.
     The issue at the heart of this powerful and unsettling film is not, as one writer puts it, "how a man could go off the rails, but how science could go off the rails." It's a question well worth pondering.



EMU Adds Autism Specialty to Master's Program
Dave Gershman, Ann Arbor News- 1/16/2008

Eastern Michigan University is starting a new master's degree program to train special education teachers to meet the needs of the growing number of children with autism. Approved by the EMU Board of Regents on Tuesday, the first 20 graduate students will enroll in the master of arts degree program in autism spectrum disorders in the 2008-09 academic year. Within three years, enrollment is planned to grow to 60 students.
      EMU officials say the new master's degree fills a pressing need. The number of children diagnosed with autism disorders has increased, and the state lacks enough special education personnel who are prepared to teach them. More than 13,000 students in Michigan schools are diagnosed with an autism spectrum disorder and there are more than 1,000 unfilled special education teaching positions in Michigan, with many of those jobs dedicated to ASD, according to EMU. "Obviously, this is a vital need and we want to help fill that need," said Sally Burton-Hoyle, professor of special education personnel, in a statement.
    The 39-hour master's degree program consists of a 12-credit core, common to all master's programs in special education, a nine-credit research component, and an 18-credit concentration in autism spectrum disorders. EMU plans to search for an additional faculty member to conduct the program.
     Tom Sidlik, chairman of the regents, said the board received many letters in support of the new program, and he read two of them aloud before taking the vote to approve the program. One was from state Sen. Tupac Hunter, D-Detroit, who urged EMU to become a forerunner in ASD education. Another was from the parent of a 13-year-old student with ASD, who wrote about her struggle to gain support from a local school district for her child.

These are some of the 40 questions on a popular version of the Narcissistic Personality Inventory. It may seem like a just-for-kicks quiz on par with “Which Superhero Are You?” but the test is commonly used by social scientists to measure narcissistic personality traits. (Choosing the first statement in any of the above pairings would be scored as narcissistic.)

Conventional wisdom, supported by academic studies using the Narcissistic Personality Inventory, maintains that today’s young people — schooled in the church of self-esteem, vying for spots on reality television, promoting themselves on YouTube — are more narcissistic than their predecessors. Heck, they join Facebook groups like the Association for Justified Narcissism. A study released last year by the Pew Research Center for the People and the Press dubbed Americans age 18 to 25 as the “Look at Me” generation and reported that this group said that their top goals were fortune and fame.

“Anything we do that’s political always falls flat,” said Ricky Van Veen, 27, a founder and the editor in chief of CollegeHumor.com, a popular and successful Web site. “It doesn’t seem like young people now are into politics as much, especially compared to their parents’ generation. I think that could lend itself to the argument that there is more narcissism and they’re more concerned about themselves, not things going on around them.”

Yet despite exhibiting some signs of self-obsession, young Americans are not more self-absorbed than earlier generations, according to new research challenging the prevailing wisdom.

Some scholars point out that bemoaning the self-involvement of young people is a perennial adult activity. (“The children now love luxury,” Plato wrote 2,400 years ago. “They have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise.”) Others warn that if young people continue to be labeled selfish and narcissistic, they just might live up to that reputation.

“There’s a self-fulfilling prophecy,” said Kali H. Trzesniewski, an assistant professor of psychology at the University of Western Ontario. Ms. Trzesniewski, along with colleagues at the University of California, Davis, and Michigan State University, will publish research in the journal Psychological Science next month showing there have been very few changes in the thoughts, feelings and behaviors of youth over the last 30 years. In other words, the minute-by-minute Twitter broadcasts of today are the navel-gazing est seminars of 1978.

Ms. Trzesniewski said her study is a response to widely publicized research by Jean Twenge, an associate professor of psychology at San Diego State University, who along with colleagues has found that narcissism is much more prevalent among people born in the 1980s than in earlier generations. Ms. Twenge’s book title summarizes the research: “Generation Me: Why Today’s Young Americans Are More Confident, Assertive, Entitled — and More Miserable Than Ever Before” (2006, Free Press).

Ms. Twenge attributed her findings in part to a change in core cultural beliefs that arose when baby-boom parents and educators fixated on instilling self-esteem in children beginning in the ’70s. “We think feeling good about yourself is very, very important,” she said in an interview. “Well, that never used to be the case back in the ’50s and ’60s, when people thought about ‘What do we need to teach young people?’ ” She points to cultural sayings as well — “believe in yourself and anything is possible” and “do what’s right for you.” “All of them are narcissistic,” she said.

“Generation Me” inspired a slew of articles in the popular press with headlines like “It’s all about me,” “Superflagilistic, Extra Egotistic” and “Big Babies: Think the Boomers are self-absorbed? Wait until you meet their kids.”

Ms. Twenge is working on another book with W. Keith Campbell of the University of Georgia, this one tentatively called “The Narcissism Epidemic.”

However, some scholars argue that a spike in selfishness among young people is, like the story of Narcissus, a myth.

“It’s like a cottage industry of putting them down and complaining about them and whining about why they don’t grow up,” said Jeffrey Jensen Arnett, a developmental psychologist, referring to young Americans. Mr. Arnett, the author of “Emerging Adulthood: The Winding Road From the Late Teens through the Twenties” (2004, Oxford University Press), has written a critique of Ms. Twenge’s book, which is to be published in the American Journal of Psychology.

Scholars including Mr. Arnett suggest several reasons why the young may be perceived as having increased narcissistic traits. These include the personal biases of older adults, the lack of nuance in the Narcissistic Personality Inventory, changing social norms, the news media’s emphasis on celebrity, and the rise of social networking sites that encourage egocentricity.

Richard P. Eibach, an assistant professor of psychology at Yale, has found that exaggerated beliefs in social decline are widespread — largely because people tend to mistake changes in themselves for changes in the external world. “Our automatic assumption is something real has changed,” Mr. Eibach said. “It takes extra thought to realize that something about your own perspective or the information you’re receiving may have changed.”

Ms. Trzesniewski gave as an example of this bias a scene from the film “Knocked Up,” in which new parents drive their baby home from the hospital at a snail’s pace. The road, of course, is no more or less dangerous than before the couple became mother and father. But once they make that life transition, they perceive the journey as perilous.

Indeed, the transition to parenthood, increased responsibility and physical aging are examples of changes in individuals that tend to be the real sources of people’s perceptions of the moral decline of others, write Mr. Eibach and Lisa K. Libby of Ohio State University in a psychology book chapter exploring the “ideology of the Good Old Days,” to be published by Oxford University Press later this year. (They also report that perceptions of social decline tend to be associated with conservative attitudes.)

Ms. Twenge and Ms. Trzesniewski used the inventory in their studies, though they chose different data sets and had opposite conclusions. Each said their data sets were better than the other’s for a host of reasons — all good, but far too long to list here. Ms. Twenge, who has read Ms. Trzesniewski’s critique, said she stands by her own nationwide analysis and has a comprehensive response, along with another paper, forthcoming in the Journal of Personality. It reads in part, “their critique ultimately strengthens our case that narcissism has risen over the generations among college students.”

Mr. Arnett dismisses tests like the inventory. “They have very limited validity,” he said. “They don’t really get at the complexity of peoples’ personality.” Some of the test choices (“I see myself as a good leader”) “sound like pretty normal personality features,” he said.

Ms. Twenge said she understands that sentiment but that the inventory has consistently proved to be an accurate measure. (She calls it “the boyfriend test.”) “There’s a fair number of personality tests that when you look at them they may seem odd, but what’s important is what they predict,” she said.

Test or no test, Mr. Arnett worries that “youth bashing” has become so common that accomplishments tend to be forgotten, like the fact that young people today have a closer relationship with their parents than existed between children and their parents in the 1960s (“They really understand things from their parents’ perspective,” Mr. Arnett said), or that they popularized the alternative spring break in which a student opts to spend a vacation helping people in a third world country instead of chugging 40s in Cancún.

“It’s the development of a new life stage between adolescence and adulthood,” Mr. Arnett said. “It’s a temporary condition of being self-focused, not a permanent generational characteristic.”



Bush Releases Billions More for Vets
Associated Press, 1/17/2008

WASHINGTON -- President Bush on Thursday released $3.7 billion in emergency money that Congress requested to care for veterans, including those returning from Iraq and Afghanistan.

Bush released the emergency funds even though he said he thought the money should have been considered as part of the normal appropriations process. The emergency money was tucked in a $550 billion government spending measure that Congress passed last month before leaving for the holidays.

''While I believe that these funds should have been considered as regular appropriations, the men and women who have sacrificed for our country should not be held hostage to budgetary wrangling in Washington,'' Bush said in a letter to House Speaker Nancy Pelosi

Sen. Daniel Akaka, D-Hawaii, chairman of the Senate Veterans Affairs Committee, said the emergency funds were needed because the veterans budget proposed by the president would have underfunded the Veterans Affairs Department at a time when there was a need to expand mental health care, improve treatment for traumatic brain injuries and reverse a claims backlog.

''This could not be allowed to happen,'' said Akaka, who wrote to the president urging him to release the extra money. ''I am relieved that he has seen fit to do so.''

Rep. Chet Edwards, D-Texas, chairman of the House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies, also applauded the president's action.

Edwards said the added funding will help pay for more qualified doctors and nurses to improve medical services for veterans.

''For the 400,000 veterans, including combat wounded vets, who are having to wait too long to have their benefits cases reviewed, this bill means over 1,800 new VA case workers to reduce the unacceptable delays in receiving earned benefits,'' he said. ''For veterans with traumatic brain injury, post-traumatic stress disorder, mental health care issues, and lost limbs, this bill means renewed hope to rebuild their lives. For many of the 200,000 homeless veterans in America, it means the dignity of not having to sleep on the streets and hope for a better future.''



Why Does Johnny Come Marching Homeless?
Associated Press, 1/19/2008

LEEDS, Mass.-- Peter Mohan traces the path from the Iraqi battlefield to this lifeless conference room, where he sits in a kilt and a Camp Kill Yourself T-shirt and calmly describes how he became a sad cliche: a homeless veteran. There was a happy homecoming, but then an accident -- car crash, broken collarbone. And then a move east, close to his wife's new job but away from his best friends. And then self-destruction: He would gun his motorcycle to 100 mph and try to stand on the seat. He would wait for his wife to leave in the morning, draw the blinds and open up whatever bottle of booze was closest. He would pull out his gun, a .45-caliber, semiautomatic pistol. He would lovingly clean it, or just look at it and put it away. Sometimes place it in his mouth. ''I don't know what to do anymore,'' his wife, Anna, told him one day. ''You can't be here anymore.''
      Peter Mohan never did find a steady job after he left Iraq. He lost his wife -- a judge granted their divorce this fall -- and he lost his friends and he lost his home, and now he is here, in a shelter. He is 28 years old. ''People come back from war different,'' he offers by way of a summary. This is not a new story in America: A young veteran back from war whose struggle to rejoin society has failed, at least for the moment, fighting demons and left homeless. But it is happening to a new generation. As the war in Afghanistan plods on in its seventh year, and the war in Iraq in its fifth, a new cadre of homeless veterans is taking shape. And with it come the questions: How is it that a nation that became so familiar with the archetypal homeless, combat-addled Vietnam veteran is now watching as more homeless veterans turn up from new wars?
     What lessons have we not learned? Who is failing these people? Or is homelessness an unavoidable byproduct of war, of young men and women who devote themselves to serving their country and then see things no man or woman should? For as long as the United States has sent its young men -- and later its young women -- off to war, it has watched as a segment of them come home and lose the battle with their own memories, their own scars, and wind up without homes. The Civil War produced thousands of wandering veterans. Frequently addicted to morphine, they were known as ''tramps,'' searching for jobs and, in many cases, literally still tending their wounds. More than a decade after the end of World War I, the ''Bonus Army'' descended on Washington -- demanding immediate payment on benefits that had been promised to them, but payable years later -- and were routed by the U.S. military. And, most publicly and perhaps most painfully, there was Vietnam: Tens of thousands of war-weary veterans, infamously rejected or forgotten by many of their own fellow citizens.
     Now it is happening again, in small but growing numbers. For now, about 1,500 veterans from Iraq and Afghanistan have been identified by the Department of Veterans Affairs. About 400 of them have taken part in VA programs designed to target homelessness. The 1,500 are a small, young segment of an estimated 336,000 veterans in the United States who were homeless at some point in 2006, the most recent year for which statistics are available, according to the National Alliance to End Homelessness. Still, advocates for homeless veterans use words like ''surge'' and ''onslaught'' and even ''tsunami'' to describe what could happen in the coming years, as both wars continue and thousands of veterans struggle with post-traumatic stress.
     People who have studied postwar trauma say there is always a lengthy gap between coming home -- the time of parades and backslaps and ''The Boys Are Back in Town'' on the local FM station -- and the moments of utter darkness that leave some of them homeless. In that time, usually a period of years, some veterans focus on the horrors they saw on the battlefield, or the friends they lost, or why on earth they themselves deserved to come home at all. They self-medicate, develop addictions, spiral down.
     How -- or perhaps the better question is why -- is this happening again? ''I really wish I could answer that question,'' says Anthony Belcher, an outreach supervisor at New Directions, which conducts monthly sweeps of Skid Row in Los Angeles, identifying homeless veterans and trying to help them get over addictions. ''It's the same question I've been asking myself and everyone around me. I'm like, wait, wait, hold it, we did this before. I don't know how our society can allow this to happen again.''
     Mental illness, financial troubles and difficulty in finding affordable housing are generally accepted as the three primary causes of homelessness among veterans, and in the case of Iraq and Afghanistan, the first has raised particular concern. Iraq veterans are less likely to have substance abuse problems but more likely to suffer mental illness, particularly post-traumatic stress, according to the Veterans Administration. And that stress by itself can trigger substance abuse.
     Some advocates say there are also some factors particular to the Iraq war, like multiple deployments and the proliferation of improvised explosive devices, that could be pulling an early trigger on stress disorders that can lead to homelessness. While many Vietnam veterans began showing manifestations of stress disorders roughly 10 years after returning from the front, Iraq and Afghanistan veterans have shown the signs much earlier.
     That could also be because stress disorders are much better understood now than they were a generation ago, advocates say. ''There's something about going back, and a third and a fourth time, that really aggravates that level of stress,'' said Michael Blecker, executive director of Swords to Plowshares,'' a San Francisco homeless-vet outreach program. ''And being in a situation where you have these IEDs, everywhere's a combat zone. There's no really safe zone there. I think that all is just a stew for post-traumatic stress disorder.''
     Others point to something more difficult to define, something about American culture that -- while celebrating and honoring troops in a very real way upon their homecoming -- ultimately forgets them. This is not necessarily due to deliberate negligence. Perhaps because of the lingering memory of Vietnam, when troops returned from an unpopular war to face open hostility, many Americans have taken care to express support for the troops even as they solidly disapprove of the war in Iraq. But it remains easy for veterans home from Iraq for several years, and teetering on the edge of losing a job or home, to slip into the shadows. And as their troubles mount, they often feel increasingly alienated from friends and family members. ''War changes people,'' says John Driscoll, vice president for operations and programs at the National Coalition for Homeless Veterans. ''Your trust in people is strained. You've been separated from loved ones and friends. The camaraderie between troops is very extreme, and now you feel vulnerable.''
     The VA spends about $265 million annually on programs targeting homeless veterans. And as Iraq and Afghanistan veterans face problems, the VA will not simply ''wait for 10 years until they show up,'' Pete Dougherty, the VA's director of homeless programs, said when the new figures were released. ''We're out there now trying to get everybody we can to get those kinds of services today, so we avoid this kind of problem in the future,'' he said.
     These are all problems defined in broad strokes, but they cascade in very real and acute ways in the lives of individual veterans. Take Mike Lally. He thinks back now to the long stretches in the stifling Iraq heat, nothing to do but play Spades and count flies, and about the day insurgents killed the friendly shop owner who sold his battalion Pringles and candy bars. He thinks about crouching in the back of a Humvee watching bullets crash into fuel tanks during his first firefight, and about waiting back at base for the vodka his mother sent him, dyed blue and concealed in bottles of Scope mouthwash. It was a little maddening, he supposes, every piece of it, but Lally is fairly sure that what finally cracked him was the bodies. Unloading the dead from ambulances and loading them onto helicopters. That was his job. ''I guess I loaded at least 20,'' he says. ''Always a couple at a time. And you knew who it was. You always knew who it was.''
     It was in 2004, when he came back from his second tour in Iraq with the Marine Corps, that his own bumpy ride down began. He would wake up at night, sweating and screaming, and during the days he imagined people in the shadows -- a state the professionals call hypervigilence and Mike Lally calls ''being on high alert, all the time.'' His father-in-law tossed him a job installing vinyl siding, but the stress overcame him, and Lally began to drink. A little rum in his morning coffee at first, and before he knew it he was drunk on the job, and then had no job at all.
     And now Mike Lally, still only 26 years old, is here, booted out of his house by his wife, padding around in an old T-shirt and sweats at a Leeds shelter called Soldier On, trying to get sober and perhaps, on a day he can envision but not yet grasp, get his home and family and life back. ''I was trying to live every day in a fog,'' he says, reflecting between spits of tobacco juice. ''I'd think I was back in there, see people popping out of windows. Any loud noise would set me off. It still does.''
     Soldier On is staffed entirely by homeless veterans. A handful who fought in Iraq or Afghanistan, usually six or seven at a time, mix with dozens from Vietnam. Its president, Jack Downing, has spent nearly four decades working with addicts, the homeless and the mentally ill. Next spring, he plans to open a limited-equity cooperative in the western Massachusetts city of Pittsfield. Formerly homeless veterans will live there, with half their rents going into individual deposit accounts.
     Downing is convinced that ushering homeless veterans back into homeownership is the best way out of the pattern of homelessness that has repeated itself in an endless loop, war after war. ''It's a disgrace,'' Downing says. ''You have served your country, you get damaged, and you come back and we don't take care of you. And we make you prove that you need our services.'' ''And how do you prove it?'' he continues, voice rising in anger. ''You prove it by regularly failing until you end up in a system where you're identified as a person in crisis. That has shocked me.''
     Even as the nation gains a much better understanding of the types of post-traumatic stress disorders suffered by so many thousands of veterans -- even as it learns the lessons of Vietnam and tries to learn the lessons of Iraq -- it is probably impossible to foretell a day when young American men and women come home from wars unscarred. At least as long as there are wars. But Driscoll, at least, sees an opportunity to do much better. He notes that the VA now has more than 200 veteran adjustment centers to help ease the transition back into society, and the existence of more than 900 VA-connected community clinics nationwide. ''We're hopeful that five years down the road, you're not going to see the same problems you saw after the Vietnam War,'' he says. ''If we as a nation do the right thing by these guys.''

An Iraq Veteran’s Descent; a Prosecutor’s Choice
Susan Sontag, New York Times- 1/20/2007

TOOELE, Utah — Not long after Lance Cpl. Walter Rollo Smith returned from Iraq, the Marines dispatched him to Quantico, Va., for a marksmanship instructor course.

Mr. Smith, then a 21-year-old Marine Corps reservist from Utah, had been shaken to the core by the intensity of his experience during the invasion of Iraq. Once a squeaky-clean Mormon boy who aspired to serve a mission abroad, he had come home a smoker and drinker, unsure if he believed in God.

In Quantico, he reported to the firing range with a friend from Fox Company, the combined Salt Lake City-Las Vegas battalion nicknamed the Saints and Sinners. Raising his rifle, he stared through the scope and started shaking. What he saw were not the inanimate targets before him but vivid, hallucinatory images of Iraq: “the cars coming at us, the chaos, the dust, the women and children, the bodies we left behind,” he said.

Each time he squeezed the trigger, Mr. Smith cried, harder and harder until he was, in his own words, “bawling on the rifle range, which marines just do not do.” Mortified, he allowed himself to be pulled away. And not long afterward, the Marines began processing his medical discharge for post-traumatic stress disorder, severing his link to the Reserve unit that anchored him and sending him off to seek help from veterans hospitals.

The incident on the firing range was the first “red flag,” as the prosecutor in Tooele County, Utah, termed it, that Mr. Smith sent up as he gradually disintegrated psychologically. At his lowest point, in March 2006, he killed Nicole Marie Speirs, the 22-year-old mother of his twin children, drowning her in a bathtub without any evident provocation or reason.

“There was no intent,” said Gary K. Searle, the deputy Tooele County attorney. “It was almost like things kept ratcheting up, without any real intervention that I can see, until one day he snapped.”

Clearly, Mr. Smith’s descent into homicidal, and suicidal, behavior is not representative of returning veterans with post-traumatic stress disorder. But among the homicide cases involving recent war veterans examined by The New York Times, Mr. Smith’s stands out because his identity as a psychologically injured veteran shaped the way that his crime was perceived locally and handled by local authorities.

Mr. Smith confessed to the killing at a Veterans Affairs hospital, which immediately set his crime in the context of his deployment and of a growing concern about care for veterans with combat stress. The fact that Mr. Smith was discharged from the Marines for post-traumatic stress disorder, or PTSD, made the prosecutor reluctant to bring the case to a jury.

“Did we want to go through a trial where basically we were going to have to defend the United States’ actions on how they treated him?” Mr. Searle said.

Nobody believes that Mr. Smith’s killing of Ms. Speirs can be justified. But many involved in the case have wondered aloud, at some point, whether Ms. Speirs’s life might have been spared if the marine’s combat trauma had been treated more aggressively.

Ms. Speirs’s parents do not engage in such speculation. They view their daughter as a victim of fatal domestic violence and not as an indirect casualty of the war in Iraq.

Last fall, sitting in their living room, across from framed samplers that said “Home Sweet Home” and “Welcome Friends,” John and Pauline Speirs remembered their daughter as a shy tomboy, a graphic designer and a proud young mother. In their estimation, Ms. Speirs herself has been ignored in all the attention given in Utah to Mr. Smith as a combat veteran.

“When they mention Nicole, it’s like an aside,” Mr. Speirs said, his voice quiet, his emotion muted. “I feel like a lot of people are using her death as something against the war. They practically are like saying that President Bush killed Nicole. Well, Walter killed Nicole. The war can be a factor. It’s not a reason or an excuse for it.”

Mr. Smith himself, in a long, dry-eyed interview in October, almost agreed. “I can’t completely, honestly say that, yes, PTSD was the sole cause of what I did,” he said, speaking through a plastic partition in a courthouse holding cell. “I don’t want to use it as a crutch. I’d feel like I was copping out of something I claim responsibility for. But I know for a fact that before I went to Iraq, there’s no way I would have taken somebody else’s life.”

Off the Preordained Path
As a teenager, Mr. Smith did not fit the prototype of the future marine. He was, in his description, “a loner and a geek” — “a math club, chess club, band and choir geek, with no interest in competitive sports past the age where you get the trophies for just showing up.”

Yet at a high school career day, Mr. Smith was drawn to the Marine Corps booth partly because the military seemed like a departure from a preordained path. “Growing up LDS,” he said, using the abbreviation for Latter-day Saints, “you’re pretty much told what you’re going to do. At the age of 19, the young men are supposed to go off on mission.”

In early 2000, Mr. Smith went off to boot camp instead, enlisting in the Reserves, like many other young Mormon recruits, so that he retained the option of mission duty.

Mr. Smith made an impression on the recruiters, scoring in the 99th percentile on the Armed Forces Vocational Aptitude Battery tests, said Christopher Nibley, a fellow reservist from Utah. “I was doing a stint in the recruiting office then,” Mr. Nibley said, “and I remember a recruiter saying, ‘Damn, that boy is so smart!’ ”

On Jan. 7, 2002 — Mr. Smith has a precise memory for dates — he received a phone call. “O.K., Smith, listen up and don’t interrupt,” an officer began. He read Mr. Smith his activation orders. Mr. Smith took a leave from a job at Wal-Mart and moved to Camp Pendleton near San Diego.

During the next year, when the Utah reservists lived in makeshift quarters on the Marine base, they bonded. Christopher Quiñones, now 32, who shared a bunk bed with Mr. Smith, described him as “a happy-go-lucky, ‘I want to go on a mission, I want to marry my high school sweetheart’ type.”

“Looking back on it,” Mr. Quiñones said, “I think Walter and a lot of guys probably should have experienced a lot more of life before we sent them off to get their heads blown off. But at that time, I couldn’t think of anybody else I’d rather go over there with.”

Mr. Smith’s superior officer, Sgt. Maj. Nick Lopez, was not as embracing. “He didn’t stand out as anything special, but he also didn’t have anything derogatory,” Sergeant Major Lopez, a Salt Lake City firefighter, said of Mr. Smith. “He was a marine who did his job, and he had a tough job, at home and in combat.”

In early 2003, the reservists of Fox Company deployed to Kuwait with the First Marine Division. After desert warfare training, they crossed into Iraq during the invasion. Crammed into the back of a large pickup truck, Mr. Smith and the other reservists traveled at a warp-slow speed at the dusty rear of a convoy miles long. Sandbags served as their armor, and, for one week, with a single M.R.E. each a day, adrenaline served as their fuel.

As they moved toward Baghdad, the gunfire cracked like whips around them, almost like sound effects for a war movie. Near Nasiriya, the reality of combat set in when they drove slowly past an amphibious vehicle containing the body parts of dead marines, their uniforms torn to shreds. Their first firefight was soon upon them.

“We were jumping concrete walls and diving headlong into it, and Walter was always putting himself out front,” Mr. Quiñones said. “Any sniper could have taken him out, but he was the type to throw himself out there to save the rest of us.”

Nothing that came before prepared the Saints and Sinners for April 8, 2003, which a New York Times correspondent later described as one of the war’s most “furious engagements.”

As dawn broke just outside Baghdad, they woke to find themselves staring at Armageddon, as Mr. Nibley said, with fires burning, helicopters shooting rockets and explosions echoing through the early-morning air. Entering the city, they climbed down from their trucks and fanned out. While the first platoon to move forward took fire immediately — with one marine shot through his helmet — others found themselves walking into the arms of exultant Iraqis.

Before long, however, as they arrived at a five-point intersection near the Republican Guard headquarters and the Defense Ministry, the cheering civilians disappeared, traffic vanished and the streets turned ghostly. As they set up roadblocks, rocket-propelled grenades and machine gun fire began whizzing toward them from the heavily defended compounds.

“I felt like I was in the middle of a duck shoot and we were the ducks,” said Mr. Smith, who was a SAW — squad automatic weapon — gunner. “I don’t know how many R.P.G.’s we took. One landed about five feet to the right of me and my buddy. I don’t know how it did not detonate, but instead it bounced. Bounced! I can’t believe we’re still alive.”

The fighting did not let up for many hours. “Whether or not I actually killed anybody with my own bullets, I don’t know,” Mr. Smith said. “I suspect so. But there were two to 12 guns going off at once, and only the snipers knew for sure.” At a certain point, the Iraqi fighters commandeered civilians’ cars, taking them hostage and ordering them to drive straight at the Marine positions. The marines were forced to shoot at everything headed their way.

“We were opening fire on civilians,” Mr. Smith said. “We were taking out women and children because it was them or us.”

Sergeant Major Lopez, his superior officer, said that his marines were “put in that position” and “trained to protect themselves first.”

“Our marines tried to limit civilian casualties,” he said. “Not a person there didn’t feel bad. But it had to be done.”

That day traumatized the reservists. Mr. Quiñones recalled a father carrying toward them the limp body of a young child. His voice cracking, he described a 5-year-old boy screaming as his car “turned into Swiss cheese.”

“I called cease-fire and I wanted to run and grab him, but there were machine gun rounds flying all around,” Mr. Quiñones said. “I watched this kid’s head get blown away, his brains splattering while his screams still echoed. Those images haunt me — haunt many of us — to this day.”

At the end of the day, 11 men in Mr. Smith’s company had been wounded but none were killed. The Iraqis fared worse. The Times’s correspondent, Dexter Filkins, described a fleeing family that lost three men, each slumped over a different car’s steering wheel. And it also described the marines, in tears, helping the wounded members of the family to safety.

Pro Forma Questions
Before they returned to the United States later in 2003, the reservists filled out questionnaires about their mental health. “Then they sat us down one after the other with an officer and he looked over the form, and said, ‘Are you doing O.K.?’ and, no matter what we wrote, we’d say yup, and then he’d say, ‘Next!’ ” Mr. Smith said.

A couple of months later, the Saints and Sinners parted company, but the Saints, some of whom were so saintly that they did not watch R-rated movies, kept close. Mr. Smith soon volunteered to go to Quantico.

After he collapsed on the firing range there, though, he disappeared from his band of brothers. “All I ever heard was Walter went nuts on the firing range, and then I never see this guy again until I see his picture on the front page looking like Grizzly Adams because he killed his girlfriend,” his fellow reservist Mr. Nibley said.

Mr. Nibley, who describes himself as adrift after two tours of duty in Iraq, said he was infuriated to learn later that Mr. Smith had been processed for discharge.

“I can’t tell you how angry I am at the Marine Corps that they just fast-tracked him out,” Mr. Nibley said. “It’s the culture and mentality of: ‘We don’t want a loser on our team. We’re not here to help you, you’re here to help us.’ ”

“I understand that we’re an infantry unit and if you’re not able to carry a gun and go into combat, that’s a problem,” Mr. Nibley said. “But we were his anchors, and we would have been his advocates. He was a mentally injured person because of his service to this country. He should not have been kicked out to go off on his own and deal with it all outside.”

The Marines do not discuss the specifics of any individual’s discharge. But the Marines do not discharge all who are diagnosed with combat trauma, said Major Eric R. Dent, a spokesman. “The goal of our competent medical professionals is to treat and return to full operational duty and full life functioning every marine who is diagnosed and treated with PTSD or any other stress injury,” Major Dent said.

Pillars of Stability Shaken
When Mr. Smith was discharged, he felt unmoored. He resumed his work at Wal-Mart, where he would stay, at one store or another, until he was arrested. He started receiving a monthly disability check of $661. He bought a place of his own, a century-old fixer-upper in Pleasant Grove, Utah. But because he no longer participated in weekend Reserve training and because he was questioning his faith, he lost touch with two pillars of his existence.

Further shaking Mr. Smith’s stability, his parents were going through a bitter divorce after 25 years of marriage and 12 children. Mr. Smith’s father moved in with Mr. Smith, his oldest son, and 2004 turned into a very difficult year for both of them.

“He definitely changed,” said Mr. Quiñones, a mail carrier, who remained friends with Mr. Smith. “After Iraq, he found it hard to care about life anymore. He became bitter to the point of suicidal.”

Mr. Smith was hardly the only one in his company to experience darkness and dysfunction. Of the approximately 40 men in his platoon, post-traumatic stress disorder was eventually diagnosed in at least 10 others, according to several of the reservists. But Mr. Smith carried the dubious distinction of being the first. As a result, he missed out on the group counseling sessions with a Navy psychiatrist that were offered on drill weekends back in Utah.

While his discharge was being processed, Mr. Smith was required to report monthly to an Air Force base in Utah, and he saw a psychiatrist there a few times. He also, reluctantly and at the Marines’ insistence, reported to the Veterans Affairs Hospital in Salt Lake City, where he attended a single group session for returning Iraq veterans.

“I’m sitting there and these guys are talking about the hard time they’re having because their supply unit heard some fire one time,” he said. “They never saw their buddies get hit. They never killed anybody. They had nothing to worry about. I never went back.”

V.A. officials, in consideration of his privacy, declined to discuss Mr. Smith’s health care. Speaking generally, Dr. Matthew J. Friedman, executive director of the agency’s National Center for PTSD, said it was “unfortunately not unusual” for veterans with combat trauma to report “for a session, maybe get some medications prescribed and a therapist assigned and never come back.” One of the central symptoms of the stress disorder is avoidance, he noted, and some veterans do not want “to retell what happened” and risk being retraumatized.

“We all would want them to come back and are trying to increase the odds that they will come back by working with community organizations, making follow-up phone calls and educating families through public service announcements,” Dr. Friedman said. “Through the retro-scope, there’s always something more that could have been done had we been able to foretell the future.”

For a while, Mr. Smith took some prescription medications to help him sleep and soothe his anxiety, but he quit the pills when they did not seem to work. Gradually, he felt himself getting worse.

“Nothing seemed to quiet the storm in my head,” he said. “I started having nightmares and flashbacks or hallucinations. During the day, I was functioning O.K., but I was feeling antsy. I couldn’t find peace.”

Two things helped: drinking — 18 to 24 cans a day of Utah’s lower-alcohol beer — and pulling a trigger. “One day, I went out skeet shooting with a buddy, and I realized I felt so much better having a shotgun in my hand and watching something explode,” he said. He bought three guns of his own.

Very late on the night of July 1, 2004, Mr. Smith reached for one of those guns after an argument with his father. Slinging it over his shoulder and grabbing 25 rounds of ammunition, he started walking toward the Wasatch Mountains. “I wanted to stop it all,” he said. “I didn’t feel like thinking about Iraq anymore. I didn’t feel like freaking out on the side of the road because someone slammed on their brakes. I didn’t feel like going rigid when I smelled diesel fuel. I was so tired. I just wanted to sleep.”

Mr. Smith left goodbye messages for everyone in his cellphone directory. One of his Fox Company buddies was awake, though, and took his call. He forced Mr. Smith to tell him his location and then he called the Pleasant Grove police. The police intercepted Mr. Smith near a trail head for Mount Timpanogos, and when he saw the officers approaching, he loaded his shotgun. He later told a close friend that he had been hoping for “suicide by cop.”

The police did not oblige. Capt. Cody Cullimore, the former assistant police chief, said Mr. Smith was compliant. He was taken to a mental health center and admitted briefly for observation.

“Sometimes I think,” Mr. Smith said, “that if I had taken my life that day, I would have saved Nicole’s.”

A Call for Help
In the fall of 2004, Walter Smith and Nicole Speirs met on MySpace. On her page, Ms. Speirs — a Scorpio, Honda lover and Utah Career College graduate — said, “I have been described as a preppie, punk, ska8er, tomboy and car chick.”

Mr. Smith and Ms. Spiers went on a few dates. Mr. Smith also dated other women.

In November, Mr. Smith called the Pleasant Grove police asking for help. The officer who was dispatched to his house was the one who had intervened in his suicide attempt five months earlier. Mr. Smith advised the officer “that he was having thoughts of taking the life of his girlfriend while she was asleep,” Captain Cullimore said. “He asked to be transferred to the hospital, which he was.”

That girlfriend was not Ms. Speirs. Once again, Mr. Smith was released after a brief stay.

Mr. Smith said that he slept with Ms. Speirs once. To her parents’ dismay, Ms. Speirs, not quite 21, got pregnant. Mr. Smith accompanied her on her first visit to the obstetrician, where she learned that she was carrying twins, but then he grew doubtful that the babies were his, he said. They broke up. Ms. Spiers was heartbroken. Mr. Smith was not. “I totally forgot about her,” he said.

Mr. Smith then started seeing another woman. One night, he came home with duct tape and demanded that the woman accompany him to the basement, said Mr. Searle, the prosecutor. Once downstairs, Mr. Smith turned to the woman and implored her to get away from him quickly before he did her harm. She ran away. The couple broke up. In a further sign of his deterioration, Mr. Smith filed for bankruptcy and moved in with a marine buddy.

Meanwhile, Ms. Speirs gave birth to twins two months early, in May 2005. Ms. Speirs was a very happy young mother but, she would confess on her MySpace page, lonely.

About seven months after the twins were born, Mr. Smith “popped onto MySpace” to see if Ms. Speirs had posted any news after giving birth. And there were the twins, he said, smiling out at him like carbon copies of his own baby pictures.

The summer after Nicole Speirs’s death, Mr. Smith began dating Michelle Zeller, a sales manager for a film company who supplied the photo labs at local Wal-Marts. Ms. Zeller, 34, knew about Ms. Speirs’s death, which she saw as a tragic accident. By September, Mr. Smith and Ms. Zeller, who has a daughter, were engaged and living together.

“He seemed pretty together,” Ms. Zeller said, “but he has told me since that he was faking it.”

Mr. Smith felt incredibly nervous, he said, that he was starting a new life, with three children involved, and that he had not “worked through my issues,” as he put it. He decided to give the veterans’ health care system another try, and soon he was commuting to Salt Lake City weekly to see a counselor, Ms. Zeller said.

“He told me they were trying to get in his head and help him deal with what had happened in Iraq,” Ms. Zeller said. “When he came home, he’d be distant and go lie down for an hour or so. One time, in late November, he slept for like a day and a half straight, waking up pale and with tremors. He seemed to be getting worse.”

On Dec. 3, 2006, Mr. Smith left the house to buy drywall at a Home Depot and never returned. “I took a left instead of a right and ended up heading to the V.A.,” he said. He called Ms. Zeller, crying, and told her he could not endure the thoughts in his head.

When Mr. Smith arrived at the hospital, he told them that he was “homicidal and suicidal.” Soon he was speaking to a counselor.

“I told them that I had done it,” Mr. Smith said, referring to killing Ms. Speirs. “The first person thought I was blaming myself for something I didn’t do. Then my uncle arrived. I told him, and he said, ‘We need to call the police.’ “

When the police arrived, Mr. Smith’s uncle told them that “Walter was essentially a good kid but that his tour in the Iraq war caused him some mental problems,” the police investigative report said.

After detectives advised him of his Miranda rights, Mr. Smith declared, “I am responsible for Nicole Speirs’s death.” It was an odd circumlocution. He declined further questioning until he obtained a lawyer.

Just before midnight, Mr. Smith’s father and uncle went to see the Speirses to tell them of Mr. Smith’s admission, which ultimately came as more of a relief than a shock. “They said Walter confessed because of us,” Mr. Speirs said. “I think he did care for us.”

At first Mr. Searle, the prosecutor, was cautious. “I didn’t want to just take his confession based on his history that we knew,” he said. Doubt was planted in part by something that Mr. Smith said to the police: “The biggest thing I want to get out of this is help.”

Further, when Matthew Jube, the lawyer hired by Walter Smith’s family, asked Mr. Smith what had happened, Mr. Smith asked him “which version” of events, the one that he had told the police or the one that he saw in his dreams. Mr. Jube began to think that Mr. Smith had given a false confession as a “cry for help,” motivated partly by guilt, both over his relationship with Ms. Speirs and about his killing of civilians in Iraq.

The prosecution had no evidence besides Mr. Smith’s confession. Although the Speirses agreed to allow their daughter’s body to be exhumed, the state medical examiner found nothing new, the prosecutor said.

‘What Is Justice?’
Mr. Smith’s lawyer sent a psychiatrist to see him a couple of times. During the second visit, the psychiatrist came away convinced that Mr. Smith had indeed killed Ms. Speirs, although he never offered any motive.

Asked during The Times’s interview why he had taken Ms. Speirs’s life, Mr. Smith said only: “I don’t feel she really had anything to do with it. Had it been someone else there at that time, it probably would have been them.”

Eventually, the prosecutor determined that Mr. Smith’s confession was valid. Then, the prosecutor said, “We fell back into, ‘What is justice?’ and ‘Justice needs to be done.’ ”

“It goes without saying that Utahans are, based on a religious perspective, very patriotic and loyal to their country,” Mr. Searle continued. “We looked at this case and said, ‘When he presents to a jury that he served his country like his country asked him to serve, and even his country admits, with his discharge and his disability pay, that he has severe psychological trauma’ — we felt there was a very good chance that the members of a jury would find him not guilty and basically punish the government for the position he’s in.”

“Washington, D.C., is 2,000 miles away,” he continued. “It wouldn’t matter to them. But to this community, it’s going to matter. We’ve got a mother of two that’s dead. Her family is affected. Her kids are affected. Walter’s affected.”

Further, Mr. Searle did not believe that Mr. Smith was guilty of murder. He felt that he was guilty of taking Ms. Speirs’s life intentionally “but acting under duress.”

“I can’t justify criminal activity,” he said. “But it would have been unjust to Walter and to society to throw out the circumstances that we as a society put him in.”

Mr. Searle and Mr. Jube negotiated an agreement under which Mr. Smith pleaded guilty to manslaughter, which, according to state guidelines, meant a sentence of one to 15 years.

During Mr. Smith’s sentencing hearing in October, Judge Mark S. Kouris of state District Court asked him if he had anything to say. Mr. Smith hemmed and hawed, mumbling that he had already addressed the judge in writing. In the packed courtroom, the insufficiency of his answer hung in the air like a gasp. Lifting his head, he forced himself to speak.

“I didn’t plan on doing what I did,” he said quietly. “I wish I could take it back, but I know I can’t. All I can say is I’m sorry. I’m not asking for leniency.”

The judge asked him to turn and address his victim’s parents directly.

“I’m sorry,” he said to them, his head falling down once more. “There’s nothing else I can say beside that.” His face crumpled, his voice cracked and his eyes watered. “I couldn’t ask for better people to raise my children,” the former marine continued, adding yet again, as his and her relatives wept, “I’m sorry.”