Fatal fallout

It is the little girl's body cut in half, her legs and bottom separated from her head, arms and torso, that regularly features in James Heer's nightmares. A guardsman in the Grenadier Guards in the first Gulf war, he "took out" three enemy bunkers on his own and was awarded medals for heroic services to Queen and country. "Now he'd like to send them all back," says Marian, his mother. "He's been left on the scrapheap."

Heer, 34, suffers flashbacks and intense fear; his concentration is poor and he has difficulty sleeping - key features of post-traumatic stress disorder (PTSD), a condition that can debilitate servicemen and women after military conflict. "It was apparent he wasn't well soon after the Gulf," says his mother. "When he came home on leave, he wouldn't go to bed. He'd sit in the armchair crying and shouting out."

Heer says he first "lost it" in 1998, three years after leaving the army without a medical discharge. "I dropped from 17 to 11 stone. I'd been a security manager, but I couldn't hold down jobs." His GP referred him to a psychiatrist in Salford, where he then lived, but he says he saw the specialist just a couple of times. "They said there was nothing they could do for him," says his mother, taking up the story after her son has left the room, too agitated to continue.

Five years later, Heer is due to see another psychiatrist, this time in Blackpool, where he has moved to live with his parents after beating up his girlfriend and trying to throw himself through a window - his third suicide attempt. He has been waiting four months, during which time the police have been called to the Heers' home to stop him smashing it up.

It is an all too familiar story: the armed forces ignoring PTSD in its early stages and the NHS failing to recognise it when veterans return to "civvy street". Mental health campaigners say the social costs are huge. A quarter of homeless people are ex-services and 5,000 former servicemen and women are in prison. Like Heer, most veterans seen by specialist mental welfare charity Combat Stress are unable to work and have broken marriages. "As well as being a serious illness for the sufferer, we are concerned about the effects on wives, carers and children," says Commander Toby Elliot, chief executive of the charity.

No one can say how high the incidence of PTSD will be among troops returning from Iraq in the coming weeks. Of the first 3,000 patients seen by the Gulf Veterans Medical Assessment Programme (GVMAP), set up by the Ministry of Defence (MoD) in 1993 to monitor illnesses from the first Gulf war, 13% were diagnosed with PTSD. Yet recent research by Roger Gabriel, a consultant physician who worked for the programme, suggests that about half the people who experience traumatic events and have a psychiatric injury do not seek medical help.

According to MoD figures, there have been 107 suicides among veterans of the first Gulf war - compared with 24 who died in combat. The Gulf Veterans Association argues that hundreds more killed in "accidents" should be reclassified.

What experts agree on is that the quicker that PTSD is identified and treated, the better. Veterans with a delayed diagnosis are likely to become more seriously ill. But it can take more than 10 years for a diagnosis to be made: Combat Stress sees veterans from as far back as the second world war. Alun Jones, a psychiatrist who runs Ty Gwyn, an ex-service personnel treatment centre in north Wales, runs 23 self-referral outpatient clinics across Britain. At the north-east clinic, he sees some 60 veterans who fought in Aden in 1967. They had never been diagnosed.

According to Gabriel, the fault lies with the medical profession. "Some military doctors are inadequately prepared for the psychological fallout of war," he says. "And GPs, hospital doctors and psychiatrists in the NHS are not asking the right questions about experiences during conflict because they are unaware of the conditions of PTSD. People come to them who have this very macho background and are hiding physical symptoms such as headaches, or they may be abusing drugs or alcohol."

Nick Preston sought help from the RAF when he returned from the Gulf after the first war. "I started drinking the day I got back," says the former Tornado refueller. "I tried to get counselling, but the RAF didn't want to know. They said I was an alcoholic and should stop drinking."

Eleven years, and five suicide attempts, later, Preston is still hitting the bottle. His former health authority told him he had an anger management problem. His current health provider, Hertfordshire Partnerships NHS trust, refuses to fund specialist care at Ty Gwyn, insisting there are adequate services locally. Preston has been given a place in a gardening group and his anti-depressants have been stopped.

"I like the gardening because it gets me out the house, but it's not helping my condition," Preston says. "Now my mood swings are worse and I go on drinking binges a couple of times a month that last a good week. It's a coping mechanism, but it means I have problems seeing my twin boys, which really gets me down."

The MoD insists procedures and attitudes have improved over the past 12 years. A Royal Navy psychiatrist, Lieutenant Commander Neil Greenberg, says: "Troops receive very realistic training and a full briefing during deployment. Each field hospital has a mobile mental health team with a psychiatrist and around four psychiatric nurses, all trained in cognitive behavioural therapy [CBT]. It is now accepted that CBT and anti-depressant medication is the way to treat PTSD."

Should veterans need help on their return from the front, Greenberg points to the 13 military community psychiatric departments and the Duchess of Kent psychiatric hospital at Catterick garrison, North Yorkshire. He denies that services are severely restricted by a shortage of military psychiatrists - 25 of 35 posts having been reported vacant last July. As importantly, Greenberg claims, there has been a distinct cultural shift in the military. "I can't say everything has changed, but it is moving away from the pure stiffupper lip," he says. "It's now recognised that traumatic stress is part of what we do."

For those whose illness is not detected in the forces, or whose symptoms emerge when they face the uncertainty of civilian life, the NHS is supposed to come to their rescue.

A Department of Health directive issued in 1997 states that ex-servicemen and women are entitled to priority medical treatment. But, according to PTSD specialists, this is widely ignored or is undermined by shortages of mental health professionals - including a shortfall of some 500 psychiatrists."When lads are sent home, they are entitled to a community psychiatric nurse," says Jones. "But we know they don't always get one because there aren't enough of them."

In order to jump NHS waiting lists, Gabriel resorted to referring GVMAP patients to specialists for private consultations, paid for by the MoD.

The Department of Health does not know how many PTSD clinics are operating in England and Wales, but a spokesman says it is aware that the level of knowledge for treating the condition is "sometimes poor" and that specialist expertise is "not always available" at local level. "The GP remains the first port of call for anyone suffering mental health problems," the spokesman says. "It is a matter for the responsible clinician to make a judgment about the treatment needed in each individual's case." Health minister Jacqui Smith told the Commons last month: "There are no funds specifically earmarked for the provision of additional specialist mental health services following any military action in the Gulf".

The Mental Health Foundation charity is calling on the government to set up a national PTSD centre for serving and former members of the forces. "This may cost millions of pounds, but early intervention would be cost-effective if you take on board the social and financial costs if the problems are left to fester," says Andrew McCulloch, the foundation's chief executive. "It's pretty scandalous that people who have been asked to die for their country are told to just shove off when they get back, and charities are left to pick up the pieces."

Heer says he has found it hard to watch televised reports from Iraq. "I see those lads and I know when they come back they'll be just like me," he says. "We used to make light of horrendous situations, because it's easier to deal with that way, but then it hits you with a sledgehammer."

He and his family pray that his new psychiatrist will recommend further treatment at Ty Gwyn, where his PTSD was diagnosed during a two-week stay just before Christmas, paid for by the Army Benevolent Fund. "They understand what I've been through," he says. "You're with other squaddies who've also seen horrendous things.

"I was a wreck when I went in. My head was scrambled, but they help you cope with it. There's no cure because you'll always have your memories, but they'll show you how to be in command of it instead of it being in command of you. I'll never be my old self, but I want to get back to work one day and not feel like a social outcast."

Belated battlescars

Judgment is expected next month in a legal action brought against the MoD by more than 250 survivors of conflicts in the Falklands, Northern Ireland, Bosnia and the Gulf who accuse the ministry of failing to diagnose PTSD and treat it adequately. Almost 2,000 potential claimants have registered an interest in the case, which could cost more than £100m.

The British military did not recognised the term post-traumatic stress disorder until 1986. "At the time of the Falklands [1982], the navy's psychiatrists thought PTSD was something that only happened to American conscripts - not to professionals," recalls former naval psychiatrist Morgan O'Connell, whose own survey of ex-Falklands officers found that by 1987 one in eight had war-related psychiatric problems.

An MoD review of the defence medical service in 1993 led to closure of military hospitals, to be replaced by military units within the NHS. These are staffed by doctors and nurses who have military and NHS patients and who, when required, can go off to war. As a result, the 30-bed Duchess of Kent psychiatric hospital at Catterick offers the only inpatient treatment available exclusively for serving personnel. In 2001-02, it received 425 referrals, of which nine were diagnosed with PTSD. The hospital is due for closure in a year's time.

Combat Stress is working with the armed forces discharge authorities to ensure that more ex-servicemen and women are aware of the treatment it offers. The charity operates an outreach welfare service and is piloting a carer support programme. Of its £5.5m a year running costs, Combat Stress receives £2m from the government to treat civilians in receipt of a war pension. However, the vast majority of the 700 new clients it sees each year have no such pension.

In contrast with provision in Britain, the US government established a network of more than 200 Vietnam veteran centres. By the mid-1980s, they were seeing 150,000 veterans a year and a further 28,000 were treated in one of 172 veteran hospitals, 13 of which had special PTSD units. However, a 1999 review concluded that long-stay inpatient programmes for veterans had been a "disastrous failure".