U.S. service members deployed to Iraq and Afghanistan can spend most of their tour waiting for a brief glimpse of the enemy.
Scanning roofs, hilltops and doorways for men with guns or rocket-propelled grenades, surveying dusty roads for homemade bombs that have injured or killed thousands of their fellow fighters -- the unending vigilance needed to survive in a war zone can take a psychological toll.
"In this conflict, you often never see the enemy," said Capt. Edward Simmer, executive officer of Naval Hospital Beaufort and a licensed psychiatrist. "The enemy planted the IED three days ago and walked away. ...
"These guys are on a heightened sense of alert at all times. Their fight-or-flight responses are activated at all times."
The residual effects of war often follow the service members home, affecting their families and the communities.
Half of all Iraq and Afghanistan veterans treated by the Department of Veterans Affairs have been diagnosed with post-traumatic stress disorder or other forms of traumatic brain injury, including many local veterans, according to the VA.
In Beaufort and Jasper counties, 98 of about 730 Iraq-era veterans on the VA's disability rolls have been diagnosed with PTSD, according to data obtained by McClatchy Newspapers through a Freedom of Information Act request.
About 325 veterans of other conflicts living in the two counties also have been diagnosed with the condition, often caused by a life-threatening event.
Although the number of veterans seeking treatment for PTSD and other mental health conditions is on the rise, Comdr. Kathy McCall knows many more suffer in silence.
"Our big challenge is helping these service members get treated when they return," said McCall, who oversees the naval hospital's branch medical clinic at Marine Corps Air Station Beaufort. "Because unless they are diagnosed before they return, we are reliant upon them seeking treatment.
"We're dealing with warriors; we're dealing with people who feel very strongly in their beliefs, and they are having a difficult time. There's anger. There's a lot of anger."
She said the Navy and Marine Corps have triedto promote treatment and de-stigmatize mental illness in recent years.
To help detect PTSD and other conditions, all branches of the military require pre- and post-deployment psychological screenings.Additionally, the Navy and Marine Corps require units to undergo stress and readiness training to help create a dialogue between Marines and sailors about combat stress.
Lt. Col. Curtis Strader, the Corps' stress and readiness training leader, said the program has the support of the branch's senior leadership and is changing attitudes about mental illness.
"It's not easy for a young Marine to ask for help," Strader said. "They're used to not needing help. They're used to providing help, but this program is showing them that it's OK not to feel OK. ... It's all about Marines taking care of Marines."
The Corps also requires units returning from combat to stay together an additional 90 days to help them ease back into life at home.
Tom Tarantino, senior legislative associate for Iraq and Afghanistan Veterans of America, applauded the military's efforts but said leaders must remain vigilant about erasing any stigma attached to mental illness.
"The top brass in the military has gotten their hands around this issue and that's critical," said Tarantino, a retired Army captain. "But we're not going to see any real change in attitudes until they can reach the command level, the sergeants, the captains and the lieutenants. They are where the rubber hits the road."
MORE TO BE DONE
The military's push to promote awareness about mental health and encourage service members and veterans to seek treatment may have overwhelmed the VA.
Since 2006, the agency says it has seen a 34 percent increase in the number of veterans seeking mental health services, reaching more than 1.2 million in 2010. It has hired about 7,000 mental health professionals to meet the demand.
However, last week, the Senate Veterans Affairs Committee called for an investigation of the VA amid allegations of long waits for appointments for veterans seeking mental health care.
Tarantino said the VA must get its act together before planned withdrawals from Iraq and Afghanistan send veterans spilling into VA hospitals and clinics.
"The reality is that getting a mental health appointment just takes far too long," Tarantino said. "You can't tell someone in crisis to come back in four weeks."
"We are at 'C' or a C-minus right now," Tarantino added. "The efforts we've seen so far are better, but slightly better than 'sucks' still kind of sucks. In a few years, we are going to see a surge in veterans coming home, and we've got to step our game up in a serious way if we're going to meet the needs of this population."
Follow reporter Patrick Donohue at twitter.com/OnBaseBeaufort.