YOKOTA AIR BASE, Japan -- Hospitalizations of troops with mental disorders such as suicidal or homicidal intent and debilitating psychosis reached a 10-year high in 2011, underscoring the mental and emotional toll of America's dual wars in Iraq and Afghanistan.
The Armed Forces Health Surveillance Center says 13,133 servicemembers were treated as inpatients last year for mental disorders, the top reason for hospitalization of active-duty troops. That was up from 10,706 in 2007.
The total number of hospitalizations for mental disorders in 2011 was about 21,700, suggesting that many patients were treated more than once, based on annual data from a recently released Medical Surveillance Monthly Report.
The number of visits for outpatient mental health treatment has also ballooned, almost doubling from just under 1 million in 2007 to about 1.89 million in 2011, the report revealed.
The number of hospitalizations is almost certainly higher because it does not include inpatient treatment of mental disorders during deployments or field training exercises, or on ships at sea.
Soldiers have particularly suffered, with their rate for mental disorders about 70 percent higher than for the Marines and more than 50 percent higher than for the Navy, Air Force or Coast Guard.
Some experts say multiple deployments with shrinking "dwell time" between them led to an emotionally debilitated force. They argue that America's all-volunteer military was not designed to cope with extended war.
Air Force Col. Christopher Robinson, deputy director for psychological health at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in Arlington, Va., said several factors likely account for the overall increase in hospitalizations.
"We're deploying people more frequently and, as a result, they're being exposed to more trauma that comes with that," with the Army bearing the brunt, he said.
Robinson described another factor as a bit of "good news." The Defense Department has prioritized reducing the stigma some servicemembers feel in seeking mental health treatment.
"With all the efforts across the department being done to reduce stigma, you're going to see more people coming forward," he said. "That means more inpatient and outpatient stays."
The department has also "vastly improved our screening and surveillance system to identify these folks and provide them treatment," Robinson said.
That includes a December 2011 directive mandating face-to-face screenings by mental health care providers for all pre- and post-deployment servicemembers -- though it came too late to play a role in last year's hospitalization numbers.
Officials ruled out any change in admission protocol as a factor for the increase, such as opting to hospitalize more patients rather than treat them as outpatients.
"We're still committed to the least restrictive environment for treatment, for care," Robinson said.
Maj. Christopher Perry, chief of inpatient psychiatry at Tripler Army Medical Center in Hawaii, said he hasn't seen the admissions threshold lowered during the past five years.
"We do what's best for the individual patient rather than set rules or use templates of what to do," Perry said. "Here at this hospital we do mostly acute stabilization and then continue the treatment as an outpatient. In general we're going to admit most homicidal and suicidal patients for safety reasons. Psychotic patients can be admitted as well, just because they can be dangerous, depending on the psychosis."
An unchanged admission protocol suggests that servicemembers have grown more acutely ill or that such extreme cases were not being hospitalized in the past.
Patrick Bellon, executive director of Veterans for Common Sense, a Washington-based nonprofit that advocates for veterans' health care, was deployed to Iraq for a year while serving in the Army in 2002-05. The prevailing command attitude toward soldiers with mental health problems was "suck it up," he said.
"On the one hand they'd say go to sick call if you're sick, but then they stand there after you go, making fun of you because you went to sick call," Bellon said. "So you wonder how many people are being driven to their wit's end by the fact no one seems to care until they're psychotic."
Dr. Stephen Xenakis, a retired Army brigadier general and psychiatrist in Washington has written about the U.S. military's general inability to assess who is fit for battle. He said he was skeptical that "practice patterns" for admissions hadn't changed and thereby contributed to higher hospital admissions for mental disorders. He added that he could only speculate about such changes without fully analyzing the data.
"There probably was a reluctance to hospitalize several years ago, and now the bar's been set lower, particularly as the concerns for suicide and other misconduct have come to light," he said.
Xenakis recalled being asked in 2007 to advise senior Army officers on what the service could do to "sustain itself and handle the stress it was under."
"There was very little serious interest at that time -- and really since that time -- in recognizing that you can't just keep driving these guys like that," he said. "Several four-stars told me flat out: 'The bigger stress is the enemy. Once we handle the enemy, everything else will be OK.' I think there's going to be a public health problem, an epidemic kind of problem, moving forward."
The all-volunteer military wasn't established to make so few serve so long, said Lawrence J. Korb, a fellow at the Center for American Progress, a liberal think tank based in Washington. Korb served for five years as assistant secretary of defense under Ronald Reagan and has written extensively about manpower issues for the U.S. military.
"This is a moral outrage that we've perpetrated on these people," Korb said. The surge in mental health-related hospitalizations is the result of sending troops into a combat zone without enough time between deployments and of accepting unfit enlistees to meet recruitment requirements, he said.
"The all-volunteer military is a peacetime force," he said. "War requires mobilization."
After a five-year hiatus, selective service registration was reinstated in 1980. It was intended to be used for a renewed draft in the event of extended war, Korb said. In 2000, the Selective Service had about 20 million men ages 18 to 24 registered, from which an ample wartime force could have been developed and deployed, he said.
"They should have renewed the draft when we invaded Iraq because then you knew you had two prolonged wars," Korb said. "They didn't want to admit that the Iraq War was going to last that long.
"Now we're paying the price for it."