Courtesy IAVA

Former U.S. Marine Sergeant Derek Coy says he still struggles "both mentally and physically, with the toll it took on me and countless others do as well."

Derek Coy hails from Baytown, Texas, and could be a poster child for American veterans of the war in Iraq as they look back and ask: "Was it all worth it?" 

A former U.S. Marine sergeant based in the volatile Anbar province at the height of the conflict, Coy is proud of his service and believes the "invaluable tools" he gained as a Marine will ultimately help him succeed in life.

But seven years since he left Iraq, he’s fighting a different battle — against anxiety, depression and emotional numbness — the effects of post-traumatic stress. 

"I still struggle, both mentally and physically, with the toll it took on me and countless others do as well," he said.

Tuesday will mark 10 years since the "shock and awe" invasion and more than a year since the last company of U.S. troops left Iraq. But only about 4 in 10 Americans who fought there — according to a Pew Research Center poll — believe the reasons for going to war justified the loss in blood and treasure.

Almost 4,500 U.S. troops were killed and more than 32,000 wounded, including thousands with critical brain and spinal injuries.  Estimates of the number of Iraqi civilian fatalities are staggering, ranging from 100,000 to 600,000.

The monetary cost could exceed $3 trillion.

While the war in Iraq has ended, the sacrifice for vets continues back in a civilian world they often find "foreign" and isolating.

Ann Weeby, a native of Boyne City, Michigan, was deployed at the beginning of the war, attached to the 101st Airborne under then-Major General David Petraeus , in the northern Iraqi town of Mosul.

"Our goal was to find weapons of mass destruction and Saddam Hussein," she said.

"After WMDs were not found and Saddam was captured, I didn’t expect [such a] prolonged U.S. military presence in Iraq," she added.

As the only person her family and friends know who fought in the war, Weeby tries to educate them about the scourges of depression and suicide that U.S. vets face after Iraq. 

"American troops are suffering, and in some cases dying, because a Veterans Affairs' claims backlog is preventing them from getting [mental] health care. Twenty-two U.S. veterans commit suicide every day!" Weeby said, citing a troubling statistic recently published by the Department of Veterans Affairs.

Courtesy IAVA

Ann Weeby, who was attached to the 101st Airborne, went in to look for WMDs and Saddam Hussein. "I didn't expect [such a] prolonged U.S. military presence in Iraq," she said.

'The cost was high'
When Leon Panetta, then secretary of defense, addressed U.S. troops in Baghdad before they pulled out of Iraq, he argued that their core mission had been accomplished.

"To be sure, the cost was high," he said. "But those lives were not lost in vain. They gave birth to an independent, free, and sovereign Iraq."

Today, however, Iraq’s Shiite Prime Minister, Nouri al-Maliki, heads what looks more like an authoritarian regime, propped up by a coercive secret service.

Toby Dodge, an analyst at U.K.-based think tank Chatham House, claimed Iraq had morphed into a pro-Iran police state, where Sunni gunmen and al Qaeda’s suicide bombers seem to strike at will, killing hundreds each week. 

His conclusion: 10 years after regime change in Iraq, little has changed.

"The lives of ordinary Iraqis, in terms of the relationship to their state and their economy, are comparable to the situation they faced in the country before regime change," he said in a report written for Chatham House.

Many Iraq War veterans admit they were fighting more for their battle buddies than for any "island of democracy" in the Arab world.

Courtesy IAVA

Robert Contreras, who had two tours of duty in Iraq, returned to California to finish a college degree, where he has struggled to relate to other students. "The most common question I get … is if I've ever killed someone," he said.

Robert Contreras, from Sylmar, California, left the military after 10 years in the Navy, including two tours of duty in Iraq, and returned to California to finish a college degree.

"Personally, I was not there fighting for Iraq," he said when asked if the war was won or lost.

"I was there to protect those who served alongside me to the best of my abilities," he said.

He’s struggled to relate to his student peers who know little about the wars in Iraq and Afghanistan.

"The most common question I get … is if I’ve ever killed someone," he said.

Contreras also developed symptoms of PTSD. "I was anxious in crowded places and unable to feel at ease anywhere but at home."

Veterans like Weeby and Coy have found a therapeutic way to generate positives from their Iraq War experiences — and better deal with some of the nagging uncertainties about Iraq’s future: They’ve reached out to their fellow vets.

Weeby is an outspoken advocate for San Francisco Bay Area veterans, while Coy is an associate at the Iraq and Afghanistan Veterans of America, or IAVA, the first and largest non-profit group representing U.S. vets from those wars.

Both are currently in Washington, D.C., part of the "Storm the Hill" offensive, pressuring Congress to address key veterans’ issues, like 9.4 percent unemployment and a bottle-necked health-care program.

"Coming home with a renewed appreciation for my life and freedoms, I’ve committed my career to helping others," reflected Weeby.

U.S. military commanders would argue that the war in Iraq brought important changes there:  Iraqis are better off without Saddam Hussein and have at least gained a fledgling democracy and national elections.

But 10 years since “shock and awe” was supposed to clear the path for a liberated Iraq and a "forward strategy of freedom" that would sweep across the Middle East, Iraqis are instead falling victim to wave upon wave of sectarian violence.

And many of their American "liberators" are fighting for their own survival — back home.

Jim Maceda has covered Iraq since the 1980s.

Related:

Concern grows about military suicides spreading within families

The enemy within: Soldier suicides outpaced combat deaths in 2012

Full Iraq coverage from NBC News

The unemployment rate among younger veterans continues to outpace the share of out-of-work civilians with nearly one in 10 ex-service members from the Iraq and Afghanistan eras hunting for jobs, according to figures released Friday by the U.S. Bureau of Labor Statistics.

Younger male veterans are dragging a collective unemployment rate of 9 percent, compared to 7.6 percent in February 2012. Younger female veterans, who have faced far stiffer challenges grabbing civilian paychecks, posted an unemployment rate of 11.6 percent last month versus 7.4 percent at this time last year, the BLS said. 

In raw numbers, 203,000 post-9/11 veterans were unemployed in February. One year ago that number totaled 154,000. Their overall unemployment rate was 9.4 percent in February. The U.S. unemployment rate last month was 7.7 percent, the Labor Department reports.

“The problem of veteran unemployment should be seen as a national disgrace,” said Cleve Geer, national commander of AMVETS, a nonprofit veterans' organization.

Many of those men and women possess — literally — battle-hardened skills, if not the ability to work under fire, yet some employers seem unable or unwilling to transfer those strengths into civilian jobs, veterans groups say.

“It’s hard for me to believe that a guy can drive a truck in combat but he can’t drive one on the highways. I mean, what the hell is that all about?” said John E. Hamilton, commander in chief of the Veterans of Foreign Wars. “You’ve got a (medical) corpsman out there in field with Marines doing everything short of open-heart surgery but he can’t be an EMT when he gets home. Are you kidding me?”

Yet the veteran-jobless rate soon may spike as sequestration forces federal agencies to hack budgets.

“That's definitely sending shockwaves around our community,” said Paul Rieckhoff, an Iraq War veteran and founder and CEO of Iraq and Afghanistan Veterans of America, a nonprofit advocacy group representing more than 200,000 members.

“One third of our members work in government some place. A lot are at the TSA, the Pentagon, and Homeland Security, working as civilians,” Rieckhoff said. “We also have a lot working in the contracting space.”

'Everybody's worried'
Among the 20 U.S. companies that hire and retain the most veterans — as ranked by G.I. Jobs — seven of those businesses cater strongly or even entirely to military personnel or federal agencies, including Booz Allen, a management consulting firm that holds contracts with the Pentagon, the Department of Homeland Security and the Department of Transportation.

“Those (contracting) jobs for veterans are definitely going to be cut back some,” said Bob Tanner, a federally employed systems analyst and former Marine corporal who served in Iraq. He was unemployed from August 2006 until February 2007 after leaving the military. “There’s still a huge gap (in veteran-versus-civilian employment). But I think that gap is going to continue to grow if there’s a lot of layoffs.”

Added Rieckhoff: “In our population, everybody’s worried.”

In late February, however, his organization partnered with Futures Inc. and Cisco to launch an online employment tool called Career Pathfinder, which Rieckhoff vows, “can be the fuel injection that gets us to deeper impacts.” The free site helps translate specialized military skills to civilian jobs. It provides thousands of active job listings from employers who want to hire veterans as well as resume-building help and a career-mapping tool.

For months, though, the employment landscape has become increasingly laced with online tools meant to connect veterans to jobs, including VetNet, rolled out last November by Google and the U.S. Chamber of Commerce’s “Hiring Our Heroes” program. Is this the innovation that finally breaks the stubborn logjam?

“We hope so. It’s definitely got tremendous potential," Rieckhoff said.

The blueprint, he added: “is taking what normally happens at a career job fair and using technology to do all that at greater scale. If you think about the overall numbers (of post-9/11 veterans), you’re talking about a couple hundred thousand people who are unemployed. So if we can get a couple thousand employed from this program, we can make a real dent.” 

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The armed forces mourned a grim toll in 2012 when more troops took their own lives than died in combat, but a precarious question remains: Why is the rate spiking when military life has long been a suicidal deterrent?

Among the services, the Army lost the most active-duty members last year to suicide: 182. Inside that branch, as two wars raged then waned, the annual suicide pace climbed. During 2001, nine out of every 100,000 active-duty soldiers killed themselves, while, during 2011, the suicide rate was nearly 23 per 100,000, according to the American Foundation for Suicide Prevention.

Compare that sobering trend to conflicts and peacetimes past. During the final three years of World War II, the Army’s annual suicide rate didn’t budge above 10 soldiers per 100,000, and during the Korean War in the early 1950s, that annual pace remained at about 11 soldiers per 100,000, according to a study published in 1985 by the Walter Reed Army Institute of Research.

Between 1975 and 1986, the Army’s annual suicide rate averaged 13 deaths per 100,000 soldiers, falling to as low as 10 in the early ‘80s, according to series of papers published in the journal Military Medicine. The Army’s suicide rate in 2001 was less than half that for all American males (18.2 per 100,000). Since then, the pace of self harm among active Army troops has more than doubled — and that trend is not ebbing: In January, the Army classified another 33 deaths as "potential suicides" among active-duty, National Guard and Army Reserve soldiers, according to the Department of Defense.

“A once-protective environment has moved to be something very different,” said David Rudd, co-founder and scientific director of the National Center for Veteran Studies based at the University of Utah.

“We need to look at the big picture to really understand what's going on today, but we all too often lose historical perspective,” said Rudd, who testified before Congress on the issue last month. The Army’s suicide pace between 1975 and 1985 should be viewed as the branch’s “baseline” rate, he added.

What has led modern soldiers to become twice as susceptible to suicide?

'The self-esteem generation'
Some answers lie in present military lifestyles and in the multiple deployments of soldiers to Iraq and Afghanistan — but also in stark psychological distinctions between today’s 20-somethings and the mindsets of past generations, according to Rudd and to veterans of recent and past U.S. combat actions.

“The fact is, nobody really understands what it means to be at a wartime, operational tempo for more than a decade,” Rudd said. “What that means for soldiers is: When they come home from those deployments, they’re never really off duty.

“They get block leave for a month or so when they get back (from war) and then they’re right back in the field, training. Even at home, you’re away from your family. That level of disconnection is a big deal,” Rudd added.

And at military garrisons on home soil, some service members stay and sleep in private quarters versus the packed barracks of long ago. Rudd said he was surprised to see such a setup earlier this year when he visited the 29 Palms Marine base in Southern California. 

“They had their own TVs, no common areas. Entitlement has grown in younger generations and society has embraced that, giving in to the entitlement,” Rudd said. The military has “made decisions in accommodating these kinds of requests for more privacy and more seclusion by isolating (soldiers) even further.

“This group is the self-esteem generation. My worry is they have not dealt with enough challenges, enough disappointments in life for many of them to build the kind of resilience that is foundational when you go to war,” added Rudd. “This has led to many of us to having thin skin. That doesn’t bode well when you go to war.”

But suicide is not solely a military phenomenon, said Cynthia O. Smith, a spokeswoman for the Department of Defense, who described suicide as “a national public health problem” and the 10th leading cause of death for all Americans.

The Pentagon has, however, rolled out numerous anti-suicide strategies during the past three years, including a 35-percent boost in the number of behavioral, health-care providers who work in primary-care clinics or who are embedded with front-line units, Smith said.

“Suicide prevention is first and foremost a leadership responsibility. Leaders throughout the chain of command must actively promote a constructive command climate that fosters cohesion and encourages individuals to reach out for help when needed,” Smith said. “Seeking help is a sign of strength.”

They went through 'harder times'
But such collective emotional strength may be lacking in today’s warriors when compared to past generations who were perhaps better steeled for battle by the epic financial hardships they faced at home, said Barry Hull, a retired Navy commander and former F/A-18 Hornet pilot who flew missions in the first Gulf War. 

“Stress is all about coping skills. World War II was just as difficult as war today. But think about what the World War II (soldiers) had just come through: The Depression. What creates our coping skills? Trauma, difficulty, adversity,” Hull said. “I’m not stereotyping individuals. I’m stereotyping populations. I’m not saying youngsters today are any less – don’t misunderstand me. But our lives tend to be a little bit less adverse. We typically do not develop the coping skills that some of the older generations did. 

“So you take a young, patriotic guy. He goes over (to Afghanistan or Iraq) and sees things he can’t even comprehend. And so what does it do? He tends to feel the effects of that stress more fully because he has not developed the coping skills that the older generation has developed,” Hull added.

One Iraq veteran who can speak intimately on the suicide epidemic is Andrew O’Brien, who was diagnosed with Post Traumatic Stress Disorder and who knew a 19-year-old soldier — with a wife and child back home — who died in an explosion. That 2009 family tragedy left O’Brien asking: “Why couldn’t it have been me?” In 2010, after returning to his Army base in Hawaii, O’Brien tried to kill himself by swallowing several bottles of pills, including sleep medication and anti-depressants. He awoke in a hospital the next day.

“That older generation, they went through harder times, the Depression, and they had so many worse things going for them. I feel like it made them more prepared,” said O’Brien, who has written an anti-suicide guide and who is scheduled to speak this weekend in New Orleans about his experiences.

But among older and younger veterans, there is one common thread that perhaps leaves both groups vulnerable to post-war struggles, O’Brien said. It is a basic tenet of Army teaching and military character.

“We are trained to be selfless. Being selfless is good when you’re deployed. You’re constantly making sure you’ve got your buddy’s back," O’Brien said. "But when you come back, it’s not good. And you have to live for the rest of your life with survivor guilt, with the fact that we lost that person.”

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Zingers about the Distinguished Warfare Medal, fired with the same deadly accuracy as drone strikes unleashed from computer screens, mock the U.S. military’s latest ribbon as “The Purple Buttocks” and “The Chairborne.”

A website about war-zone burn pits offers a photoshopped version of the medal as a glossy, gold Xbox controller. At Stars and Stripes, one writer quipped the fresh decoration — announced Feb. 13 by Defense Secretary Leon Panetta to honor troops who direct cyberattacks and drone strikes — has ignited “an avalanche of Whiskey Tango Foxtrots.” And at an online store run by current and ex-military members, retailers joke that any recipients will have earned the award from “the safety of some air conditioned box while sipping on their mocha-frapachino [sic] that they picked up on the way in to work that day, and waiting for Papa John’s to show up with lunch.”

Boom. 

The shrapnel-packed jabs seem to be fueled as much by the non-combat medal's mere existence as by the decoration's rank: the Distinguished Warfare Medal is slotted by military brass slightly above the Bronze Star, long the fourth-highest combat award granted for heroism and/or meritorious service in battle.

Many of the so-called "Distant Warfare Medal" critics — and cutups — fully acknowledge the strategic value of cyber experts within the U.S. armed forces, especially as President President Barack Obama on Friday deployed American service members and drone aircraft to the African country of Niger, where they could be used to support a French counterterrorism mission in neighboring Mali.

Still, some can't help but smirk at the thought of a keyboard clicker eventually being pinned with a ribbon. And there are those in the service who thought the first mentions they read about the medal were a just a dash of military satire. After all, for men and women in uniform, sarcasm and dark humor are as common as camo and Hesco (a protective barrier). 

"I thought it was a joke at first," said Marine Sgt. Jeremy Lattimer, 26, who earned a Bronze Star for his actions in Afghanistan's Helmand Province where, in one three-hour stretch on Nov. 22, 2009, he led his squad as they maneuvered through enemy machine gun fire then helped another squad escape an ambush.

"When I saw that this has a higher rating than the Bronze Star, it seemed a little bit extreme," added Lattimer, reached by phone at Walter Reed National Military Medical Center, where he's receiving treatment for a traumatic brain injury sustained in combat. "Whenever you start getting into (awarding) valor for someone in a box behind a computer in who knows where, I think that's a point where it starts rubbing people the wrong way."

Meanwhile, some military families are so disturbed by the new medal that punchlines seem out of line. 

Courtesy of Veronica Ortiz-Rivera

Marine Staff Sgt. Javier Ortiz-Rivera was heavily decorated in life. After dying in action, he was awarded the Bronze Star. In 2009, he and his wife, Veronica (left), attended the Marine Corps Ball.

Near Camp Lejeune, N.C., where Marine Staff Sgt. Javier Ortiz-Rivera was based before his 2010 IED-blast death in Afghanistan, his wife, Veronica, speaks softly and somberly about the value of the Bronze Star that the Marine earned posthumously. 

"To know that somebody sitting at a computer who never risked their life is going to get something that’s worth more, it almost puts less of a value on what my husband did and what so many other men have done," Ortiz-Rivera said. "To take that new medal and give it a higher classification than the Bronze Star and the Purple Heart is disrespectful. Maybe I’m just biased because my husband was killed in combat.

"It feels like it almost strips away a little of his heroism, honestly, although he is and always will be a hero to us," she added. "I'm not at a point where I can joke about" this new medal.

And for Army veteran Andrew O'Brien, who served in Afghanistan in 2008 and 2009, any humorous takes about any medals — no matter how they are earned — simply feels wrong, he said. 

"We are all on the same team," O'Brien said. "I believe they (drone operators) deserve medals just as much as anyone else and recognition for the things they do. I also feel (the humor) is an attack on them for what they do. To mimic a video game as an award? We are all part of the same fight."

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• Home from war, troops face 'white-knuckled' first month 

Kate Singh / Clark County Historical Museum

Victoria Parker's tattoos honor five soldiers in her unit who were killed in Iraq during her second deployment there.

The five men are not her brothers. But that’s what she calls them.

The five initials are not for her children. But many who spot her non-sleeved left arm ask if the tight stack of black letters represents her kids. The question bothers her.

From the top of her booming bicep — where “M.G. 27 JAN 07” is positioned — to the bottom of the bulge — where “B.E.” rests — Army Reserve Drill Sgt. Victoria Parker’s limb permanently honors the five fellow soldiers in her unit who were killed in Iraq during her second deployment there. Images of those those tattoos also went on display Tuesday as part of “Vet Ink,” an exhibit at the Clark County Historical Museum in Vancouver, Wash.

“The motto is: ‘Always remember, never forgot.’ I told them I would always remember them. And by putting it on my arm, I remember them every day. I think about them every day,” said Parker, 27, who lives in Vancouver. Her largest, accompanying tattoo depicts the “fallen soldier battle cross” — a helmet poised on a standing rifle placed inside empty, unlaced boots. That was inked from a photo she snapped of the memorial shrine set up for Army Sgt. Blair Emery (“B.E.”), killed in a roadside bomb attack in 2007 in Taji, just north of Baghdad.

“The tattoos helped me cope and move on and still honor their memories,” Parker said. “It’s no longer painful.”

“Vet Ink” is the brainchild of Susan Tissot, executive director of the museum, located in a city rich with Army roots. Before the Civil War, then-Capt. Ulysses S. Grant was quartermaster at the Columbia Army Barracks in that town. Vancouver has also served as home to part of the 104th Infantry Division.

Kate Singh / Clark County Historical Museum

Tattoos on the back of Jeremy Hubbard.

“The Army is very prevalent in everything we do — there are a lot of veterans here, a lot of Army personnel and our former mayor was a colonel in the Army. My father-in-law is a retired Naval officer,” Tissot said. “It’s a very personal exhibit.

“I knew the tattoos told a story," she added. "It’s a very touching story." 

“Vet Ink” spans military members who served from the 1950s through to today’s armed forces — 11 veterans (or active members or reserves) spanning every branch but the Coast Guard. Each panel details their time in uniform as well as when and why they decided to get tattooed.

Some of the images, like those gracing Parker’s arm, represent the “memorial” category of ink art that recall the fallen or a certain battle. Among military tattoos — a tradition that sprouted among Navy sailors generations ago but now are commonplace among post-9/11 veterans — are the other three classes: “patriotic” (flags, eagles), “spiritual” (a star, a cross, the Virgin Mary), and “identity,” (a specific unit, battalion or division), according to Kristina Wells, the museum’s collections manager.

“There’s been an interesting evolution in what tattoos the military would even accept. Our Vietnam veteran in the exhibit and one of the other 1960s service guys who took part didn’t get their tattoos until they were in their 60s. It was less accepted by the military back then,” Wells said. “If you were tattooed, you maybe wouldn’t even be accepted into the Army and Marines (during that era).”

Later, military regulations were relaxed, and banned tattoos on the neck and face.

Kate Singh / Clark County Historical Museum

Christian Nippolt-Vetter.

The ink also once carried something of a “hidden” code, especially in the Navy, according to the museum. For example, the image of a sparrow or swallow signified having traveled 5,000 or more miles. Tattoos of pigs or roosters were good-luck charms meant to prevent drowning because those animals often were carried in wooden crates, which would float if the ship ever sank.

For Parker, the tattoos also serve as a shorthand account of her combat experiences for any other veterans who spy them — an “automatic understanding” and a “unifying symbol.” She said she and fellow veterans can read one another’s service history from their ink.

But for those who haven’t served, she said, there is often misunderstanding.

“I get a lot of people asking me if they’re my kids. That’s frustrating and hurtful,” Parker said. “The female veterans, we’re so invisible. People don’t assume we’re veterans at all.”

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Jessica Mcgowan / for NBC News

Former Marine Paul Menefee, an Iraq war veteran, makes music in his Union City, Ga bedroom, on Feb. 15. Since transitioning to civilian life, Menefee works as a music producer in Atlanta. At home, Menefee spends most of his time in this blacked out bedroom making music and relaxing. Drawing blinds and blacking out windows is a habit Menefee started after his military service to help him feel more secure.

In the first month home from war, one Marine routinely searched his darkened bedroom for the rifle he'd left in Iraq, while another Marine shunned his favorite nightspot for fear that someone in the club might carry a gun. 

In the four weeks after their homecomings, one infantryman drove “white knuckled” at 55 mph while another soldier purposely began living even faster — losing her virginity, going blonde and drinking hard with battle buddies.

Some 34,000 service members will ship home from Afghanistan during the next year, President Barack Obama told the nation last week. 

Amid the gleeful glow of arrivals, many of those troops may quickly confront sensory overloads, social awkwardness and, perhaps, deep cravings for personal freedoms, according to interviews with four younger veterans who weathered such moments.  

“The first 30 days are interesting,” said Alex Horton, who spent 15 months in Iraq as an Army infantryman, including during the 2007 troop surge in Baghdad and Diyala Province.

Today, he works for the Department of Veterans Affairs. "I’ll call it the unraveling. That first week back you’re still high on everything, kissing your wife or girlfriend, sometimes seeing your kids for the first time. But then the tension starts to build.

“You experience culture and weather shock, and notice your senses are heightened,” said Horton, adding that another common theme — albeit something he did not go through — involves disrupting the daily routines established by a spouse and kids during a service member’s absence, and consequently, dealing with strained relationships. 

Distant from family
To that point, two veterans interviewed for this story, including Horton, said they suffered romantic breakups after returning from combat, and two got divorced. 

Jessica Mcgowan / for NBC News

Former Marine Paul Menefee, an Iraq war veteran, shows off his spiritual tattoos at home in Union City, Ga., on Feb. 15. The "Blessed" tattoo is one many Menefee has gotten after his two tours in Iraq.

"Trying to get back to my regular life was hard because I wouldn’t talk much to anybody. I didn’t want to talk about what went on in Iraq, didn't want to describe the details," said Paul Menefee, a former Marine who was deployed twice to Iraq and fought in the Battle of Fallujah in late 2004. 

"Things that happened, I didn’t want to remember. I was trying to cope in my own way, not deal with the images in my head," added Menefee, who eventually divorced his wife. "I was distant from my wife, mother, cousins, brothers, sisters, aunts, uncles. At Sunday dinners, I pretty much stayed off to myself."

Old habits came home, too. During his first 30 days back at Camp Lejeune, N.C., Menefee grew jittery in a Wal-Mart checkout line because other customers were queued up behind him. He left the store immediately. He avoided nightclub outings with friends because the bar crowds seemed unpredictable.

He chose seats in the backs of restaurants so he could watch all the patrons and map each exit. At home, he kept his blinds drawn, his door locked and always looked left then glanced right when passing a hallway or an open corner. 

On interstate highways, Menefee — a truck driver in Iraq — often pulled four lanes to his left if he spotted a blown tire or crumpled, food wrapper lying on the right shoulder: The types of hiding places in which insurgents routinely planted IEDs in Iraq. While driving in an American city, he would take an early left or an abrupt right if he saw garbage or roadkill on an approaching curb.

"You don’t realize that (your senses are) very fine-tuned to your environment, everything from hearing things to seeing things," Horton said. "I imagine this is what blind people feel with their other senses. You rely on them so much (in combat), they have no business being that acute in the civilian world."

"When I got into a car and drove on a highway for the first time," Horton added, "I was white knuckled."

For former Marine Christian Gutierrez, who returned from Iraq in spring 2008, the open road at first carried a mix of old caution and fresh freedom.

During quick trips to the grocery store, he frequently would exit his car then quickly circle back, thinking he'd left his rifle in the front seat, momentarily forgetting he didn't carry a weapon anymore. 

"But I love cars and love driving. So I drove a lot because it was my time," Gutierrez said. "That moment was your moment. You had control of your car. You had control of that moment."

'Lucky I didn't die'
Soon, he bought a motorcycle to further feed that rush of independence, to expand his new-found personal space — and because combat left him with another sharp bit of wisdom: Your moments on this planet may be few.  

"Being back taught me that if I want to do something, I’d better do something right now. You never know," he said. 

That same compulsion drove Iraq veteran Laura Cannon to use her first 30 days home to mark, she said, "the beginning of a new life for me," a time in which she stepped away from both Evangelical Christianity and the strict rules under which she'd been living since enrolling at West Point.  

"I knew that if I didn't make drastic changes, being at war would be the last adventure I would ever experience," said Cannon, a former Army infantry member who was part of the 2003 Coalition invasion. "Surviving a war completely changed my perspective. I needed to start living for me. So I made a mental list of goals to accomplish. No. 1 — lose my virginity. I was 24 for God's sake!"

During her first month home, Cannon also bought an SUV, broke up with a boyfriend, dyed her hair blonde, visited Ground Zero, posted a personal best in a 5K race, and found time to "party my ass off with my war buddies — heavy drinking."

In Iraq, "there was (stuff) blowing up everywhere. I'm lucky I didn't die. I hadn't done enough with my life," she said. "I had survived a war. I had a second chance to live differently. I was not going to let others control me anymore. It was time to make more adventures and maybe get some baggage along the way. I was so far behind. Lots to catch up on."

"The rapid pace at which I compensated for my repressed life, especially in the first 30 days after the war," Cannon added, "were completely catalyzed by combat." 

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Eighty percent of veterans who attempted suicide and survived had received mental health care one month earlier from the Department of Veterans Affairs, underscoring the potential peril of 50-day average wait times they face in trying to access VA treatment, a suicide expert told a Congressional committee Wednesday.

“When they had contact a month prior, the question I ask is: How long was it until their next (VA) appointment? Was it scheduled six weeks out? Is that the problem? Or was it scheduled one week out?” David Rudd, head of the National Center for Veteran Studies, testified before the House Committee on Veterans’ Affairs.

“My concern is — from the individuals I talk with that we treat to surviving family members of those who have died — often times, it’s an issue of the (VA) system getting in the way to keep an appointment, to get an appointment, or to get to an appointment,” Rudd said. 

According to a VA report released earlier this month, 18 to 22 veterans commit suicide each day. And that rate “has remained steady” since the Iraq and Afghanistan wars began 12 years ago, said Veterans' Committee chairman Rep. Jeff Miller, R-Fla., who noted that during that same span the VA has increased its budget by 39 percent and its staffing by 41 percent.

“When a veteran is in need of care, the difference of a day or a week or a month can be the difference between life and death,” Miller said. “ ... Something somewhere is clearly missing.”

In his State of the Union address Tuesday night, President Barack Obama announced that 34,000 U.S. troops would head home from Afghanistan during the next year.

Given that mammoth flow of young veterans into an already-backlogged VA system, Miller questioned whether the agency’s “one-size-fits all approach” will leave thousands of ex-service members mired in a bureaucracy that “fails to recognize that addressing mental-health needs ... is a task that the VA cannot handle by themselves.”

“We’ve improved our services for veterans but we know there’s a lot more work to be done,” testified Dr. Robert A. Petzel, the VA’s undersecretary for health.

In 2012, for example, the VA’s 24-hour crisis line fielded 193,000 phone calls that resulted in more than 6,400 “rescues” of veterans who were threatening to hurt themselves or their family members, Petzel said.

While the volume of calls to the hotline is increasing, fewer of those calls are “acute” — or people making an imminent threat — “demonstrating that VA’s early intervention appears to be working,” Petzel added.

What’s more, in the past year, VA has hired 1,058 new mental-health providers and the agency expects to meet its hiring goal of 1,600 extra clinicians by June, Petzel testified, adding that last year 1.3 million veterans received mental-health care from the VA, up from 927,000 in 2006. That increase, he contends, shows that “proactive screening” is working to find and treat veterans for Post Traumatic Stress Disorder, depression, substance abuse issues, and the effects of military sexual trauma.

“Your focus is on the process, the number of people hired. Numbers, numbers, numbers,” Miller responded. “The most important number is the number of veterans getting healthy, healthier or helped.”

“It’s time for us not to do the same thing,” Rudd agreed. “More of the same thing isn’t working ... The way we’ve (tried to address these problems) over the years since the start of these wars is we’ve made the VA larger. I think the evidence would suggest the VA does not need to be larger. I was not encouraged when I heard they’re hiring over 1,000 individuals.”

Instead, Rudd testified, VA should partner with the Department of Defense’s health system TRICARE “because their providers are already in those small communities and available."

“That means shifting money to a non-traditional model,” he added. “But that’s how you connect people to people” instead of linking individual veterans into a vast system.

Related: 

• Soldier Hard's hip-hop lyrics reveal PTSD's rough edges
• 22 veterans commit suicide each day: VA report
• Concern grows about military suicides spreading within families

President Obama awarded the Medal of Honor to celebrated Army veteran Clinton Romesha on Monday afternoon, making the former active duty staff sergeant just the fourth living person to receive the military’s highest honor for service in Iraq or Afghanistan.

Romesha, 31, fought back tears as Obama presented him with the medal honoring his “conspicuous gallantry” during the Battle of Kamdesh, a day-long firefight at a remote Afghan outpost near the Pakistan border in 2009.

“These men were outnumbered, outgunned, and almost overrun,” Obama said in his remarks in the White House East Room. 

Romesha was recognized for leading the charge against hundreds of Taliban fighters during an Oct. 3, 2009, siege on U.S. troops at Combat Outpost Keating, a small compound military officials considered indefensible. 

Eight American soldiers were killed and 20 were wounded in the surprise attack, making it the deadliest day for the U.S. in the war effort that year.

Romesha headed up efforts to retake the camp, risking his own life as U.S. troops were besieged by rocket-propelled grenades, machine guns, mortars and rifles.

Romesha, who served twice in Iraq, first took out a machine-gun team and then turned to a second, suffering shrapnel wounds when a grenade struck a generator he was using for cover.

An official citation read at the ceremony described Romesha’s subsequent acts of valor.

"Undeterred by his injuries, Staff Sergeant Romesha continued to fight and upon the arrival of another soldier to aid him and the assistant gunner, he again rushed through the exposed avenue to assemble additional soldiers," the citation says.

“With complete disregard for his own safety, (he) continually exposed himself to heavy enemy fire as he moved confidently about the battlefield engaging and destroying multiple enemy targets.”

Previously reported: "He's always been a good kid." 

All the while, Romesha devised a strategy to secure key points of the battlefield and directed air support to eliminate a band of thirty heavily armed enemy combatants.

Slideshow: Medal of Honor recipients

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A look at heroes from a post-9/11 era of war

Launch slideshow

Romesha and his team also provided cover so three injured soldiers could make their way to an aid station. They then “pushed forward 100 meters under withering fire to recover the bodies of their fallen comrades,” according to the citation.

Romesha, a father of three and the son of a Vietnam veteran, reportedly never lost his composure during the chaotic attack, according to CNN journalist Jake Tapper, who chronicled the battle in the 2012 book "The Outpost."

'Clint is a pretty humble guy'
During his remarks, Obama recognized the lives of the eight soldiers who died at the Battle of Kamdesh, asking the parents of the fallen seated in the back of the room to stand for applause. 

But the heart of Obama's speech centered on a visibly emotional Romesha, who appeared to be fighting back tears as he looked ahead at his wife, Tammy, and three young children.

"Clint is a pretty humble guy," Obama said. "The thing he looks forward to the most is just being a husband and a father."

Romesha is slated to be a guest of first lady Michelle Obama at the State of the Union address on Tuesday, CNN reported.

At a January news conference shortly after Obama called to inform him that he would receive the Medal of Honor, Romesha put the attention squarely on wounded friends and fallen comrades.

"I've had buddies that have lost eyesight and lost limbs," Romesha said. "I would rather give them all the credit they deserve for sacrificing so much. For me it was nothing, really. I got a little peppered, that was it."

Romesha, whom Tapper describes in his book as "an intense guy, short and wiry," lives in Minot, N.D., and works at KS Industries, an oil field construction firm.

A total of ten U.S. service members have been awarded the military's highest honor for actions in Afghanistan and Iraq, including six men who received the honor posthumously. 

The Medal of Honor is bestowed on members of the U.S. Armed Forces who display what the Army calls "conspicuous gallantry and intrepidity at the risk of life above and beyond the call of duty."

Sleep-starved from a repeating nightmare and weary from wondering when all that therapy would reignite his fading hope, former Army tank gunner Jeff Barillaro took aim at his stubborn target with an attack as brilliant as it was simple.

He decided to break up with PTSD.

And he would do it in his increasingly famous style — studio-recorded hip-hop, under his stage name, Soldier Hard.

“I thought: If I could write a letter to PTSD, what would I say to PTSD? Then I thought: Oh, wow, this is going to be powerful,” said Barillaro, an Iraq War veteran, out of the service since 2010, who has steadily gained fame among active-duty troops, young veterans and their families for his bare, often-bleak music about the daily demons of living with severe Post Traumatic Stress Disorder. 

Last May, “Dear PTSD,” streamed from his busy mind to his scribbling fingers and, ultimately into a microphone: “Did you listen good when I said, Leave me be? PTSD, get the hell away from me. Cuz you held me down, didn’t even let me sleep, didn’t even let me breathe, didn’t let me live in peace.”

Courtesy of Omar Diaz Photography

Jeff Barillaro, a.k.a. Soldier Hard.

Within the genre of modern military music, Barillaro has ventured a bit further from the mainstream with his growing stockpile of PTSD songs — lyrics and beats tapped from his anger, isolation, divorce, and what he calls “my dark world,” all byproducts, he believes, of extended combat tension and witnessed war horrors.

He has recorded 14 albums, laying down his first tracks on “a minimum setup” at Camp Taji, Iraq, where he discovered that “between missions I could create music as my escape.” He has launched a nonprofit record label, Redcon-1 Music Group, that already boasts a roster containing an Air Force staff sergeant, a Navy sailor, Marine Staff Sgt. Jerry Lozano, and two Army soldiers, including Fort-Hood-based Spc. Stephen Hobbs.

'Music has saved my life'
“I wanted to give other military artists and veterans a chance to tell their stories,” Barillaro said. “Because I know how much music has saved my life. Maybe it can save their life, too.

“I want them to know that same feeling I get when it comes to music, when I’m writing it, and when I’m done and I’m listening to it. I forget where I’m at, any problems I’m having, any bills I can’t pay. It keeps my mind clear. It keeps me sane. That’s why I believe music can really heal people.”

Some of the fans Barillaro has attracted say they are alive only because of the ex-gunner’s lyrical lash outs at anxieties affecting an estimated 20 percent of the men and women who served in Iraq and Afghanistan.

One night in 2007, former Army Corp. and Iraq veteran Keith Briggs said he “was sitting at the computer with a bottle in one hand and a gun in the other,” contemplating shooting himself. He had been diagnosed with PTSD in 2005 just after returning from his second deployment.

Courtesy of Jeff Barillaro

Jeff Barillaro looks at old records of former Iraqi prisoners at Camp Taji, Iraq, after U.S. forces took control of the base.

“For some reason I decided to get on Youtube and I found his song ‘Support Us.’ It changed my outlook on PTSD,” said Briggs, 30, who lives in Shelbyville, Ky. “I knew I was not alone. Soldier Hard's music has saved my life. It has stopped me from suicide. PTSD is a real threat to veterans. Soldier Hard’s music is the tool to fight this."

PTSD expert Dr. Sydney Savion, a retired military officer who has heard Barillaro’s songs, said many of the artist’s themes — particularly when he confronts PTSD — could evoke positive emotions in listeners with post-combat stress. They feel, she said, that he is speaking directly to them, forging a vital bond across the Internet and reinforcing the notion that they are not alone as they all strive to recover.

“Research does suggest that certain music can regulate negative emotions,” said Savion, a Texas-based applied behavior scientist. “But conversely, some therapists have found some music with spoken words or lyrics could cause and has caused agitation when its played for those diagnosed with PTSD. So there is a duality between whether the music will evoke a positive feeling or whether it will conjure up those memories that can cause negative feelings. Not everyone’s going to respond to the music in the same way.

“But there is no definitive line that a rapper should or shouldn’t cross,” she added, “because each individual will respond to it differently.”

'Telling horror stories'
Of course, the quiet irony underscoring Barillaro’s art: PTSD has typically — and purposely — remained a private struggle for many young war veterans. Within the military, the unofficial mantra has been: “Take care of your own business,” or worse: “Getting help is for the weak.” That has affixed PTSD with a social stain common to other mental health issues.

Barillaro, however, has literally shouted out almost every step of his path away from PTSD, stigma and all.

At first, he admits, he was tentative about revealing too much.

“I didn’t want to be looked at as a weak person, and I didn’t want people to be scared (of me). But I was just going to say it because it’s how I feel,” Barillaro said. “And I know there’s a lot of people out there who feel the same way I did. So I decided: I’m going to write it and I’m going to start telling horror stories.

“And then it became not about myself anymore. Because I started seeing how much the music would help other people. Then I was like: Alright, I’m just going to let loose now and let everything out because these people out there are going through same thing I was going through and this gives them some hope.”

The music has helped him. It hasn’t cured him completely. The old nightmare still haunts his sleep: He’s with his buddies in a “Middle Eastern setting,” he said. They begin to take fire from the enemy. His friends are shooting back. But in the dream, Barillaro tosses away his weapon, hides his head and begins sobbing.

“That same dream always, always. But that’s not how I reacted while I was in combat. I was on it," he said. "I don’t even sleep anymore when I wake up from one.”

Courtesy of Jeff Barillaro

Jeff Barillaro, a.k.a. Soldier Hard, crouches in an abandoned building at Camp Taji, Iraq, in 2005

Which — to no one’s surprise — inspired a song released last July: “Intro-Therapy Session.” He takes listeners inside a conversation with a psychologist during which he is asked about any nightmares he’s been experiencing.

“I’m scared, crying and I’m frightened. Then I wake up hella sweaty," he raps. "Tell me why this be. I just wanna die, please tell me: Why me?”

The song’s final verse — accompanied by an ominous, sharp pop and a woman's scream — is not pretty. But, as Barillaro has been preaching all these years, neither is living each day with PTSD. 

Related:

• Hundreds of thousands of veterans spurn free benefits
• Some wounded vets thrive on 'Alive Day,' others wear black
• One inch: Death in combat hinges on the tiniest margins

The weekend homicides of ex-Navy SEAL and “American Sniper” author Chris Kyle and a friend in Texas have stoked fresh concerns among mental-health experts and veteran advocates that the crime’s PTSD theme will further stigmatize and dampen an already-soggy job market for men and women home from war.

“What worries me about this story is it will frighten potential employers away from hiring veterans who have been in Iraq and Afghanistan,” said Dr. Harry Croft, a San Antonio-based psychiatrist who has talked with more than 7,000 veterans diagnosed with Post Traumatic Stress Syndrome.

“The myth is all of them have PTSD  — not true, only 20 percent.  Another myth is that all of them who have a severe case of it — not true; it goes from very mild to severe. The third myth is that everybody with PTSD is aggressive, unreliable, or trouble in the workplace, and none of that is (true) either. It scares me,” Croft said.

The unemployment rate for post-9/11 veterans was 11.7 percent in January compared to 9.1 percent in January 2012, according to the U.S. Bureau of Labor Statistics. Younger female veterans grappled with a 17.1 percent unemployment rate last month — virtually unchanged from one year ago — while the unemployment rate for younger male veterans was 10.5 percent in January, which marked an increase from 7.7 percent during the same month in 2012.

“One of the things I talk about in the presentations I give to employers is how the stigma of the crazed vet like Sgt. (Robert) Bales, or, now, this young man in Texas, is very rare and it’s atypical. Now, that doesn’t mean that a vet with PTSD doesn’t have anger and agitation issues. But generally, it’s worse at home than it is at work,” said Croft, who co-authored “I Always Sit with My Back to the Wall: Managing Traumatic Stress and Combat PTSD.”

Eddie Ray Routh, 25, a Marine Corps corporal from 2006 to 2010 who deployed to Iraq in 2007, was arraigned Sunday on two counts of capital murder in the deaths of Kyle, 38, and Chad Littlefield, 35, at a shooting range in North Texas. Both men were killed with a semi-automatic handgun.

According to Erath County Sheriff Tommy Bryant, Routh "may have been suffering from some type of mental illness from being in the military himself." Bryant added that Routh's mother possibly contacted Kyle to try to help her son. The sheriff also learned, he said, that the three men might have been at the range “for some type of therapy that Mr. Kyle assists people with.”

Some veterans who toil in the job-mentoring trenches to try to deflate those unemployment stats share Croft’s concern that Texas shootings may bolster an existing PTSD stigma and inject more doubt into the minds of some hiring managers.

“Unfortunately, I think that’s a possibility,” said John E. Pickens, executive director of VeteransPlus and the Yellow Ribbon Registry Network. VeteransPlus has offered financial counseling to more than 150,000 current and former service members. The nonprofit also has partnered with The WorkPlace, Citi and Wal-Mart to help long-term, unemployed veterans improve their job candidacies and find work.

“But I’m not sure how to address that (stigma) because for those people who read something like this and take away a negative impression, it’s very difficult — other than having a one-on-one, good experience with a veteran — to be able to overcome that,” said Pickens, a former Army combat medic.

Iraq veteran Ed Richardson, who’s now attending college but who’s been scouting for a job since December 2011, has watched employers offer subtle signals about his war service during job interviews.

“I’ve had people’s body language completely change with me — their eyes get large and they want to lean back in their chair” when the topic arises with hiring managers, said Richardson, 49, who is in the Army Reserves and who lives in Kentucky. “Some ask me: ‘Have you had any issues? Because some veterans have had the problems.’

"Being a veteran and having that going against me (in job hunting), you have to have something to counter it and I believe having an associate degree can help, or preferably a bachelor’s degree,” Richardson said. He ideally wants to work in federal law enforcement. “But I’m very positive about my outlook.” 

Related: 

• Murder of former Navy SEAL turns spotlight on veteran hunting and shooting clubs
• Ex-Navy SEAL sniper Chris Kyle died pursuing his passion
• Florida guide uses hunting as rustic therapy for combat veterans

Firing bullets at a gun range — as a Marine reservist was doing Saturday when he allegedly killed ex-Navy SEAL and "American Sniper" author Chris Kyle — can ignite combat flashbacks, a leading expert on post-traumatic stress disorder said Monday, adding, however, that hunting and target practice can be therapeutic for veterans if their shooting buddies intimately know war.

“The question being asked is: Wouldn’t the shooting of a weapon out in the open trigger feelings, nightmares, flashbacks? The answer is, yes, it can,” said Dr. Harry Croft, a San Antonio-based psychiatrist who has talked with more than 7,000 veterans diagnosed with PTSD. “But the hope would be that those would be triggered in a situation that’s safe, where other people are there who understand PTSD and could help the person cope with the thoughts that may come back to them.

“In situations like a shooting range, the sounds may set off a hyper-vigilant response, maybe flashbacks and nightmares at night. But it doesn’t make you violent, like you’re going to kill the person around you. And if the person around you is a Chris Kyle, a Navy SEAL who knows and can support you, then that experience can have a more positive effect,” Croft said.

Eddie Ray Routh, 25, a Marine Corps corporal from 2006 to 2010 who deployed to Iraq in 2007 and Haiti in 2010, was arraigned Sunday on two counts of capital murder in the deaths of Kyle, 38, and Chad Littlefield, 35, at a shooting range in North Texas. Both men were killed with a semi-automatic handgun.

According to Erath County Sheriff Tommy Bryant, Routh "may have been suffering from some type of mental illness from being in the military himself." Bryant added that Routh's mother possibly contacted Kyle to try to help her son. The sheriff also learned, he said, that the three men might have been at the range “for some type of therapy that Mr. Kyle assists people with.”

Organized veteran hunting excursions and shooting clubs — meant to be part bonding experience, part brief return to comfortable turf and tools — have proliferated across the country in recent years, particularly as American troops departed Iraq and as they continue to pull out of Afghanistan. Croft estimated that about 20 percent of Iraq and Afghanistan veterans have a form of PTSD, ranging from mild to severe.

“I talk all the time about the importance of good support systems for those suffering from PTSD, and articulate, bright, fellow military members like Kyle might have an ability to help a young troop with PTSD more than most (others) might,” said Croft, who co-authored “I Always Sit with My Back to the Wall: Managing Traumatic Stress and Combat PTSD.”

“That’s why it would be very rare if, all of a sudden, (the suspect) got triggered feelings and then would turn the gun and shoot this guy in the back. Something happened that we don’t know or understand, I believe,” said Croft, who has never worked with Routh. “This behavior is totally atypical for people with just PTSD. There can be rage, anger, aggression, agitation, even violence, yes. But it’s generally directed toward family members or one’s self, in terms of this suicide epidemic. Rarely is it outside of that circle.”

The U.S. Department of Veterans Affairs has occasionally partnered with the Tampa, Fla.-based Black Dagger Military Hunt Club to hold shooting programs for veterans. In July, the club is sponsoring the trap shooting competition for the 2013 National Veterans Wheelchair Games in Tampa, providing ammunition and clays. Black Dagger, made up of ex-military members, also holds four to six shooting events per year. Every participant is briefed beforehand by “range safety officers" and supplied weapons. The veterans then work one-on-one with expert shooters, said founder Dave Winters, a 20-year Air Force member who retired as a senior master sergeant.

“We tell them: If at any time you feel uncomfortable about what’s going on out here, if the noise is too loud, put your weapon down, talk to your range safety buddy and just indicate that you need to walk away,” Winters said.

“We’ve had several who were real uneasy about approaching it at first, but once they saw that it was a comfortable thing, (and of course that) no one is shooting at them, that’s what I think helps them. It kind of normalizes them,” Winters said. (One Afghanistan veteran in the club), who feels like no one can relate to him, said that when he’s back out at the range, shooting and talking, it's just like when he was in his unit. It just makes them feel a lot better.”

In central Florida, the Sportsmen’s Foundation for Military Families escorts combat veterans — and their spouses, children, parents or siblings — onto leased land for weekend hunting trips.

“We never cater to just the veteran. Two veterans — or a group of veterans — who are out in the woods together, that does not improve coping skills, generally speaking. What improves their coping skills is their family,” said Barry Hull, a retired Navy commander and F/A-18 Hornet pilot who flew on the first night strike of Desert Storm. He has helped the Sportsmen's Foundation on the business side and attended several hunts.

The group is based on the concept that hunting trips “give the veteran and family a sense that they can once again be like they were, that those good days can be had again, particularly with those who have physical injuries and limitations,” Hull said.

“What improves a veteran’s coping skills is their family. And I know a lot of people want to say, 'Well, they're my military family.' They’re really not your family. Your family is really what I would call the classical definition of family — that's it for the long haul,” Hull said. “If you can develop those coping skills, communication picks up at home. We know that just simply being able to identify your demons lowers the effect (of PTSD). And that's what we do when we get the family out there on these adventures.

“The worst thing you can do is get a bunch of veterans out there in the woods, whooping and hollering and telling war stories, maybe drinking some beer, and not including the family. What does it do? It drives a bigger wedge between the veteran and the family. It's another distance maker,” Hull added. “What does that do? It adds more stress.”

Related:

• Ex-Navy SEAL sniper Chris Kyle died pursuing his passion
• 'American Sniper' author Chris Kyle fatally shot at Texas gun range
• Florida guide uses hunting as rustic therapy for combat veterans