Afghan rampage prompts PTSD debate in US military town
As a US soldier is held for the massacre of 16 Afghan civilians, there are growing concerns at his home base about post-traumatic stress disorder (PTSD).
Staff Sgt Robert Bales, who was sent to Iraq three times before his recent deployment to Afghanistan, returned to the United States on Friday.
His lawyer, John Henry Browne, has said the accused could be suffering from PTSD.
Talk to people who live around the sprawling military base of Fort Lewis-McChord - one of the largest in America and home to more than 100,000 personnel, including Sgt Bales - and you will find they know all about post-traumatic stress disorder.
As the population of this base in the north-western state of Washington has grown - and war zone deployments have increased - so too has the amount of suicide and violence.
Last year, the military newspaper Stars and Stripes labelled Lewis-McChord the "most troubled" base in the US military.
But it is claimed that cases of PTSD were not just being overlooked - they may actually have been deliberately downplayed.
At the base's Madigan Army Medical Center, an investigation is currently under way into allegations that the diagnoses of hundreds of soldiers suffering from PTSD may have been altered to lesser conditions in order to save on disability costs paid by the army.
Seattle-based mental health therapist and PTSD counsellor Reid Stell says: "A PTSD diagnosis never goes away. To say you're cured… that would be overly optimistic."
'War is trauma'
As to whether Sgt Robert Bales could have had his diagnosis altered in such a way, a US military spokeswoman told the BBC in a statement that they keep service members' health information private and do not comment on medical records.
Navy veteran Matt Bambara, 29, volunteers at a cafe, Coffee Strong, near the Lewis-McChord base.
He told the BBC he believes many problems in the community have been caused by people with untreated cases of PTSD.
"The military ought to be held accountable for the health and well-being of soldiers," Mr Bambara said.
The words "war is trauma" are painted on a wall of Coffee Strong, and Mr Bambara says he witnesses PTSD behaviour among some of his customers.
"People come in with high levels of anxiety," he says. "You can almost see it in their face in terms of the way they are looking over their shoulders and constantly looking out of the window and are just kind of generally suspicious and just distrustful."
Is the military doing enough?
"I don't think they are," he says. "I don't think they have the capacity.
"The fact is they wouldn't be able to function and perform their mission if they were to genuinely compensate and allow the proper healing to take place."
Dr Harry Croft, former Army doctor and psychiatrist, who has evaluated more than 7,000 veterans for PTSD, says the rampage in Afghanistan means it is time for the military to take a closer look at the impact on soldiers who serve multiple tours.
A study in 2008 by RAND Corp, a think tank, indicated that 18% of all service members returning from Iraq and Afghanistan since 2001 had PTSD or major depression. Only about half were seeking help.
"They're reluctant for fear that it could affect their military career," says Mr Stell, on why so few soldiers reach out for PTSD and depression treatment.
Others say PTSD is too often used as a diagnosis or as an "excuse".
"Some people say PTSD because it's an easy diagnosis, in my opinion," says Steve Binda, 67, a retired US Army veteran who served in Vietnam.
He says men he knew fought in the trenches and survived the horrors of World War II, coming back home to continue on with their lives post-war.
PTSD deaths at home
Sue Rothwell, 63, owner of Gerties, a local restaurant and bar popular among the soldiers and veterans, isn't surprised that some soldiers snap.
"You take an 18-year-old off a farm in Minnesota, for example, send them over there and then wonder why he can't deal with it," she says.
In January 2010, US soldier Joshua Tabor was convicted of assault after holding his four-year-old daughter's head under water when she could not remember her alphabet properly.
In April 2011, Sgt David Stewart, a medic assigned to the Lewis-McChord base killed himself and his wife after leading authorities on a high-speed car chase.
They subsequently found the couple's five-year-old son dead at their home.
Last week, Lt Col Robert Underwood, a national guard trainer, was charged with allegedly hiring a hit man to kill his wife and his superior officer. He also threatened to blow up the Washington state capitol.
All three men in these cases were said to have been suffering PTSD, and all were based at Lewis-McChord.
Will anything come of the recent killing and maiming of 16 civilians in Afghanistan?
Some mental health experts are sceptical.
Mr Stell worries that the incident will be brushed off as the actions of a rogue soldier.
"This is what it takes," he says. "A big headline-grabbing event, but will it be the bad apple argument."