Nearly half of the 2.2 million U.S. troops who served in Iraq and Afghanistan have struggled to readjust to American life in part because the Departments of Defense and Veterans Affairs have been sluggish in helping those coming home in droves, according to a sweeping report released today.

After examining veteran suicides and unemployment as well as the military’s handling of sex assaults, women in uniform and same-sex family issues, the Institute of Medicine said returning service members deserve “timely and adequate care,” yet it cited cases in which the DOD and VA are using unproven diagnostic and therapy tools.

"The (federal) response has been slow and has not matched the magnitude of this population's requirements as many cope with a complex set of health, economic, and other challenges," said co-author Dr. George Rutherford. He chairs the IOM’s committee on the assessment of readjustment needs of military personnel, veterans, and their families. The IOM, an independent nonprofit, is the health arm of the National Academy of Sciences. 

"The number of people affected, the influx of returning personnel as the conflicts wind down, and the potential long-term consequences of their service heighten the urgency of putting the appropriate knowledge and resources in place to make re-entry into post-deployment life as easy as possible,” added Rutherford, head of preventive medicine and public health at the University of California, San Francisco School of Medicine.

Another 34,000 U.S. service members will be flown home from Afghanistan during the next 12 months. The high suicide toll among veterans (22 per day) has drawn recent Congressional scrutiny as have the elevated veteran-unemployment rate and access limits to VA mental health care. Congress requested the IOM study. 

Among the recommendations within the 500-plus page report:

• DOD and VA must “boost efforts to reduce the stigma” associated with service members or veterans simply asking for help to deal with mental-health issues or with substance-abuse problems.
• The tool DOD uses to assess cognitive function following a head injury – Automated Neuropsychological Assessment Metrics (ANAM) — carries “no clear scientific evidence” to show that it works. That’s key because more than 200,000 U.S. troops have sustained traumatic brain injuries since 2000 — most non-combat-related. On March 5, Congressional members sent a letter to the chiefs of DOD and VA seeking data to investigate a new theory linking TBIs with the military’s suicide crisis.
• One of the VA’s “first-line treatments for depression” — Acceptance and Commitment Therapy — similarly “lacks sufficient evidence” to show its efficacy.
• Research has found that curbing access to lethal weapons prevents suicides, however, “DOD policy prohibits restricting that individual's access to privately owned weapons” — even if a service member is known to be at risk for suicide.
• DOD and VA should link their databases so that the health records of all service members are available to track their medical conditions from the moment they enter the service through the day any future treatment is eventually rendered by a VA facility. 

"These (recommendations) are meant to be helpful, meant to be more of a roadmap of how to pursue” these issues, Rutherford said. “These are extraordinary challenges that the systems are facing and they’ve gone to extraordinary efforts to try and work with them.

'Demand is large'
“Yeah, it can all be streamlined. Yeah, (the available help) can be matched better to the demands. Yeah, you can improve this stuff. But they are trying like crazy to make it match the demand,” he added. “The demand is large, and it’s growing.”

Compared to past post-war generations, a higher percentage of returning Iraq and Afghanistan Veterans are using the VA for their health care — 56 percent of that population, according to the VA.

"This report provides VA a better understanding of the difficulties some Veterans face as they readjust to home, reconnect with family members, find employment and return to school," read an email from Josh Taylor, a VA spokesman. "Greater collaboration with the Department of Defense (DoD) in the areas of research, treatment and clinical outcomes will further enhance continuity of care as service members transition from active to veteran status."

Pentagon officials will examine the IOM’s suggestions, said Cynthia O. Smith, a DoD spokeswoman.

“DoD appreciates IOM's hard work and will thoughtfully consider the study's key findings and recommendations,” Smith wrote in an email. She added that the agency’s Deployment Health Clinical Center “will work collectively with the VA to provide a joint response to Congress no later than June 2013.” 

The IOM study reports that 44 percent of veterans have had "readjustment difficulties," 48 percent have dealt with "strains on family life," 49 percent have experienced post-traumatic stress, and 32 percent have felt "an occasional loss of interest in daily activities." Those figures were plucked from an earlier Pew Research Center survey. 

"I’m not surprised (by those numbers), talking to my other buddies that have gotten out. I’ve got several buddies that still can’t find jobs but, to be honest with you, I think it's a factor of (their) motivation" to hunt for work, said Ryan Kriesel, 24, an Army tank operator who served two tours in Iraq. He's now a student at the University of Minnesota. He described his own transition as "pretty smooth." 

When it comes to those younger veterans who report a flagging interest in daily life, Kriesel believes some of that may be due to the loss of the emotional rush that once came with combat. 

"Part of it is being back in the civilian world," he said. "There’s not as much adrenaline going on as when you were overseas, out on combat missions several times a day."

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• Obama urged to step in to fix VA backlog

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

Traumatic brain injuries sustained by more than 200,000 U.S. troops may be fueling the military’s suicide crisis, according to a letter co-signed by 53 congressional members who are seeking additional data to investigate the new theory.

In the letter, sent Tuesday to Defense Secretary Chuck Hagel and Veterans Affairs Secretary Eric Shinseki, the lawmakers urged both agencies to provide Congress with a raft of figures, including the number of Iraq and Afghanistan service members and veterans who committed suicide or tried to end their lives after being brain injured by the detonation of an improvised explosive device — “the weapon of choice” in both wars.

“Evidence has suggested that blast injuries, including but not limited to those causing damage to vision or hearing, can have a severe psychological impact ... that can play a major contributing role in suicides,” read the bi-partisan letter.

Between November 2011 and October 2012, there were more than 15,000 IED attacks against U.S. service members in Afghanistan, and 58 percent of all coalition casualties during that span were caused by the hidden bombs, the letter states.

At least three veterans groups, including the Blinded Veterans Association, are backing the congressional push to — as the letter to DOD and VA states — “get a better understanding of the connection between blast injuries and suicide.”

“I’ve talked to a lot of neurologists, military neurosurgeons and trauma surgeons who have all started to ponder if the IEDs that have caused the TBIs are the real cause of the suicides, versus the traditional approach that suicides are all caused by the psychological stresses of combat,” said Thomas Zampieri, head of government relations for the Blinded Veterans Association.

“Let’s collect more information and maybe the epidemiologists will find a way to unlock some of this mystery: Are military suicides actually more related to the brain injuries? I think there may be a big connection,” added Zampieri, who served as a Vietnam-era Army medic. “As the numbers of TBIs go up, the numbers of suicides continue to go up.”

The portion of U.S. service members who sustained TBIs increased each year from 2001 to 2011 — with a total of 266,810 brain injuries diagnosed in American troops between 2000 and 2012, according to the Defense and Veterans Brain Injury Center, part of the DOD. More than 80 percent of those injuries were not deployment-related cases, with many occurring amid crashes of privately owned cars and military vehicles. 

Army soldiers account for the vast majority of diagnosed TBI cases, and those injuries range from “mild” (a concussion) to “severe.” Within the Army, the suicide rate among active-duty members has risen from 9 per 100,000 in 2001 to nearly 23 per 100,000 in 2011, according to the American Foundation for Suicide Prevention.

During that same span, according to the DOD’s brain injury center, the number of annual TBI diagnoses among American troops has ballooned from 11,580 in 2001 to 32,609 in 2011 — an increase of 182 percent.

“What is significant is that we are looking at a potential paradigm shift of significant proportion if the link between low-level TBI from IEDs emerges,” said retired Army Col. Bob Morris, founder of the Global Campaign against IEDs.

“The current automatic approach is to connect everything to Post Traumatic Stress Disorder and look at it all as psychological when it may be a physiological,” Morris added. 

The lawmakers additionally asked the DOD and VA to supply "specific autopsy findings (of service members or veterans) potentially indicative of prior TBI." The members said they want to know whether such post-mortems found "chronic traumatic encephalopathy", which has been detected in the brains of a number of NFL players who recently committed suicide. 

Numerous Iraq and Afghanistan veterans have been diagnosed with both TBIs and PTSD, as well as with hearing loss — the most common disability among the men and women who served in those wars. 

"There is no higher priority for VA than the mental health and well-being of our courageous men and women who have served the nation," said a VA spokesman, responding to the congressional letter. "Under the leadership of Secretary Shinseki, VA has made significant progress in providing increased access to mental health care services and strengthening our suicide prevention efforts, but there is more work to do. VA is committed to providing all Veterans the care and benefits they have earned and deserve.”

A Pentagon spokeswoman said Hagel "responds directly to correspondence received" and that it would inappropriate for her comment on the letter. 

Rep. Dan Benishek, R-Mich., a surgeon who worked at a VA medical center for 20 years, led the effort to collect congressional signatures for the letter to Hagel and Shinseki.

“Far too many of our veterans and military personnel have taken their own life after bravely serving our nation. Frankly, it’s tragic and unacceptable,” Benishek said in a statement Tuesday. “I am hopeful that by working together we can make sure our guys and gals in the military and the VA have the support they need to recover from the damaging psychological effects of war.”

"There is particular evidence linking suicide to those wounded by IEDs," added Rep. Richard Hanna, R-N.Y. "It is my hope that through additional research we will be able to identify and reverse this painful trend. One suicide is too many and we should do all we can to address this as quickly as possible."

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• Home from war, troops face 'white-knuckled' first month
• Soldier Hard's hip-hop lyrics reveal PTSD's rough edges

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.”

Related:

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• Home from war, troops face 'white-knuckled' first month
• Soldier Hard's hip-hop lyrics reveal PTSD's rough edges

Christopher Dorner, the former LAPD police officer who carried out a vengeful rampage against his fellow ex-cops and others, died of a single, self-inflicted gunshot wound to the head at the end of an intense firefight with police in rural Big Bear, Calif., authorities said Friday.

At a late-afternoon news conference, San Bernardino County authorities said that the cause of death was determined by an autopsy conducted Thursday by the county Coroner’s Office.

Authorities had been unsure whether Dorner killed himself, had been struck by a deputy's bullet or had died in a fire that engulfed the cabin during the shootout. The coroner's finding still must be finalized.

In their most detailed account to date of the final days and hours of the hunt for Dorner, 33, San Bernardino County sheriff’s officials said they tried to force the suspect to surrender before accidentally setting the cabin where he was holed up on fire when they shot a pyrotechnic chemical device inside.

Sheriff John McMahon also detailed the extent of the arsenal that Dorner had with him in his final days, which he spent eluding searchers in the mountainous area east of Los Angeles.  Among the items recovered from the cabin where Dorner died and other locations and vehicles were numerous assault weapons; semiautomatic handguns; a .308-caliber, bolt-action sniper rifle; high-capacity ammunition magazines; a total of 10 suppressors or silencers; tear gas and smoke canisters; a military-style load-bearing vest; and a military-style Kevlar helmet, he said.

The sheriff also confirmed that Dorner spent most of his time on the run hiding in a condominium just steps away from the command center set up to find him. He said deputies had visited the unit, which was locked, on the evening of Feb. 7, but received no answer when they knocked on the door and then moved on.

Robyn Beck / AFP - Getty Images

Christopher Dorner

“It was locked and nobody answered,” he said. “… We were not going to kick the doors in.”

Sheriff’s Capt. Gregg Herbert also elaborated on the tactics used during the confrontation with Dorner at the cabin in the Seven Oaks area, saying that when deputies responded to the scene they noticed tracks in the snow in front of the cabin where Dorner had taken refuge.  As Deputy Alex Collins, Detective Jeremiah Mackay and other officers were conversing in the street in an attempt to devise a plan to check on the cabin, Dorner opened fire on them, striking both deputies multiple times, Hebert said. The other deputies returned fire, and dodged an onslaught of bullets to get to the injured officers and drag them out of the line of fire, he said.

MacKay died later at an area hospital; Collins remains hospitalized after undergoing multiple surgeries. Dorner died hours later inside the cabin, after he and law enforcement officers exchanged hundreds of rounds.

Police had been seeking Dorner since last week, when they say he launched a deadly revenge campaign against the Los Angeles Police Department over his 2009 firing.

Related story

Police chief named in manifesto recalls 'the Chris Dorner that I knew'

 Before launching his onslaught, he posted a rambling 1,400-word manifesto on Facebook in which he allegedly wrote that killing was “a necessary evil” to avenge his firing  and also threatened other law enforcement officers and their families.

Before killing the deputy in the San Bernardino mountains, Dorner is suspected of slaying a couple in Irvine and a police officer in Riverside.

“Self Preservation is no longer important to me,” he wrote in the manifesto, a copy of which was made available to the media by authorities. “I do not fear death as I died long ago on 1/2/09.” 

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

Al Hartmann / The Salt Lake Tribune file

Michael Powell, facing camera, locks a gate after becoming concerned about Michael Peterson, a former friend of Joshua and Susan Powell who showed up at the West Valley City home on Jan. 6, 2010, to collect a playgound set he gave the Powell children to use.

The brother of Josh Powell, the Utah man who killed his two young sons and himself in an intentionally set house fire about a year ago, has committed suicide, according to police.

Michael Powell, 30, jumped from a seven-story parking ramp near his home in downtown Minneapolis around 2:25 p.m. on Monday, the Salt Lake Tribune reported. He died on impact.

Four people apparently witnessed the fall, a police report said, and the Hennepin County Medical Examiner’s Office confirmed Powell’s death.

Michael Powell was a doctoral degree candidate in cognitive science at the University of Minnesota, the Tribune reported.

He was a fervent defender of his brother, Josh, who murdered his sons, Charlie, 7, and Braden, 5, with a hatchet and then lit a match to a can of gasoline in a rented house near Puyallup, Wash., on Feb. 5, 2012. The house exploded within moments, killing all three.

Days before the explosion, Powell had been denied custody of the children and ordered to undergo a psychosexual evaluation after police discovered hundreds of images of disturbing cartoon sex and graphic depictions of incest on his home computer.

At the time, he was the only person of interest in his wife’s disappearance. In December 2009, Susan Powell, 28, went missing in Utah, where the family lived. Powell had told police that she had run away from their family during a midnight camping trip.

Powell had also been in a legal battle in U.S. District Court for Western Washington with Susan’s parents Chuck and Judy Cox over $1.5 million in insurance policies issued to the family.

Several months before his death, Powell changed his insurance policy to list Michael as the primary beneficiary rather than Susan. Michael was to receive a 93 percent share, and if Michael died, the insurance payout would be split evenly between his sister and father. Powell also made Michael the second beneficiary on his sons' insurance policies.

Michael Powell also fiercely defended their father, Steve Powell, who was convicted in May 2012 of 14 counts of voyeurism for surreptitious photographs he took of two girls who lived near his home in Puyallup. Powell said he believed the charges against his father, is scheduled to be released in May, had been fabricated.

Interactive map: A long weekend of gun deaths. Click to enlarge.

It was after midnight, early on a Saturday in the college town of Moscow, Idaho, and student Jason "Cowboy" Monson was at the police station to get back his Desert Eagle .45-caliber handgun.

In McDonough, Ga., about the same time, two teenage brothers were still awake. A friend was sleeping over, and their mother had let the boys handle her .38-caliber revolver, which was unloaded. She'd gone to bed.

In South Valley, N.M., it was quiet at the Griego household as 15-year-old Nehemiah waited for his father to come home from the night shift at a homeless shelter. The son was holding his father's AR-15 semi-automatic rifle.

In the next few hours, the freshman in Idaho, one of the brothers in Georgia, and most of the Griego family would be dead, victims of three forms of gun violence — suicide, accident and murder — that are everyday occurrences in the United States.

Their deaths, and scores of others, occurred over a holiday weekend, the third weekend in January, when America celebrated the memory of Dr. Martin Luther King Jr., a victim of gun violence. It also was the weekend the nation swore in a re-elected president whose inaugural address referred to guns, though he didn’t actually say the word: "Our journey is not complete until all our children, from the streets of Detroit to the hills of Appalachia to the quiet lanes of Newtown, know that they are cared for, and cherished, and always safe from harm."

San Antonio Express-News via Zuma Press

One of 91 deaths identified by guns across America on a long holiday weekend: Officers with the Bexar County, Texas, Sheriff's Office investigate the shooting death of Jesse Rosas, whose bullet-riddled body was found on the side of a road near San Antonio on Jan. 21. Police have not identified any suspects.

By the end of the long weekend — after President Barack Obama had spoken and the red, white and blue confetti strewn along Pennsylvania Avenue had been cleaned up — at least 91 people across America had been killed by guns. That's more than three times the number of caskets needed in Connecticut after the shooting at Sandy Hook Elementary School. These 91 people died, not in a single burst of violence over a few minutes, but spread over a three-day weekend, like an autoworker stealing an entire convertible one part at a time to escape notice.

In the aftermath of the Dec. 14 Newtown shooting, during a renewed national debate about gun rights and gun control, NBC News picked the weekend of Jan. 19-21 to examine gun deaths across America. Today and on Monday and Tuesday, we'll tell you what we found and introduce you to some of the victims and their families. We also invite you to look at our online map and to draw your own impressions from the stories of violence.

We don't pretend to have found all the gun deaths over that weekend. There is no official census of gun deaths, and it takes the federal government many months to compile national crime and suicide statistics. We drew our list from the deaths that were reported in the press, and confirmed the details with authorities in all but a few cases. If you only want to know how many people are killed by guns on an average day in America, simply divide the annual figure, about 31,300, by 365 days, and there's your average: about 86 people a day.

Why did we find “only” 91 in three days? The main reason is that hardly any suicides get reported in the media. Suicides by gun are twice as common as gun homicides. Some homicides don't get any publicity either. Unless a killer chooses a public place, annihilates an entire family or shoots up a Wal-Mart, he might not even get on a website, in the newspaper or on TV, not on a holiday weekend competing with the festivities in the nation's capital and the Ravens-Patriots and Falcons-Seahawks games. The Griego family massacre in New Mexico was the only incident that long weekend to get significant national news attention. It also could be that holiday weekends with NFL championships are safer, with so many young men – who are statistically far more likely to shoot someone — inside instead, watching the games.

Guns by the numbers: how violence adds up

Our goal was not, however, merely to count the deaths, but to share the stories of the people who died, to see what lessons one might learn from those whose deaths usually go unnoticed, that don't prompt the president to order the White House flag to half-staff.

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It's an inescapable conclusion, even from our small sample, that there are many ways to get killed with a gun in America.

Based on interviews with police, prosecutors and family members in all but a few of the cases, we tallied 53 homicides where one person killed another. There were another three homicides where multiple people were killed. There were six murder-suicides, and six suicides. Five accidental shootings. Three shootings by police, and at least two by civilians in self-defense. That's 78 horrors with 91 dead. On a different randomly chosen weekend, the count might shake out differently.

You can get killed throwing your daughter a 17th birthday party, if your angry estranged husband shows up. Without a gun, you might have an angry confrontation and maybe some tears. With a handgun, the birthday girl in Grapevine, Texas, lost her mother and father in a murder-suicide, police said.

Or you can get killed buying a taco from a vendor on the street in Los Angeles, if you get into an argument with the wrong person, and that person has a gun.

Or catching a train: A bystander was killed at a Bay Area Rapid Transit station in San Leandro, Calif., when a couple of gangs started trading shots.

You can get killed spending an afternoon with grandma. Just as the president was beginning his inaugural address and talking about making children safe, a gunman in Cocoa, Fla., burst into a home before a children's birthday party, shooting to death the mother of several of the children and seriously wounding their grandmother.

Or visiting a strip club. A U.S. Army soldier from Oklahoma's Fort Sill was killed outside a strip club during a dispute over a woman.

Manatee County Sheriff's Office

James Brady, 26, was shot and killed in Bradenton, Fla., Jan. 20, as he and two other masked men attempted to rob a resident in his carport, police said.  One alleged robber, Jared Lee, has been charged with felony murder in Brady's death. Authorities are seeking a third man, Charles Jones.

You can get killed for what may seem like like a pretty good reason, if, as the National Rifle Association’s Wayne LaPierre put it after the Newtown shooting, you're a “bad guy with a gun” who happens to run into a “good guy with a gun.” There were two shootings by citizens that apparently were justified over the long weekend, including one by a man in Bradenton, Fla., who was ready with his own handgun and a concealed weapons permit when three armed robbers wearing masks confronted him and his roommate in their carport, according to police. He killed one of them, and authorities determined it was in self-defense. There also were three shootings by police officers that have tentatively been ruled as justified, including one in which an ex-con was shot dead after he threatened to kill his hostage following an armed robbery.

Las Vegas Police

Las Vegas Police Lt. Hans Walters, 52, killed his wife, former police officer Kathryn Michelle Walters, and their 5-year-old son, Maximilian, called 911 to confess and then set his house on fire on Jan. 21, according to police. Walters killed himself with the handgun as police moved in.

But as we saw last week when a former Los Angeles police officer allegedly went on a murderous rampage against fellow law enforcement officers, the “good guys” aren’t immune to the demons that trigger gun violence. Over the inaugural weekend, a Las Vegas police lieutenant used a handgun to kill his wife, herself a former police officer, and their 5-year-old son, before killing himself, according to police, just as the president was taking his seat on the West Front terrace of the U.S. Capitol on Monday morning.

You can get killed when your fists are outgunned, like the 22-year-old man who his family said was standing up for his friends in a brawl, when someone else pulled a gun and shot him dead, according to police. They were in Torrance, Calif., attending a punk rock festival headlined by a band called "Aggression."

You can become an ironic headline, like the 20-year-old man in Lafayette, La., who was shot dead about 60 yards from the Martin Luther King Jr. recreation center, on Monday, the day when Dr. King's legacy of nonviolence was being celebrated. That shooting occurred about the time the Obamas left the White House for their inaugural ball.

Or you can be ignored as just another victim of a street crime or a drug deal, barely making the local newspapers if you're killed in a "confrontation at a mobile home park" or "shot and killed in an argument in a parking lot."

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One of the surprises in our snapshot of gun violence was how young many of the victims were.

Oregon State Police

Kayla Ann Hendrickson, 16, was killed alongside an Oregon highway on Jan. 19, by her boyfriend, Jacob Allen Green, 24, after an argument, according to police. Green committed suicide near the California border, they said.

Twenty of the 91 were too young to buy a beer at a baseball game. There's the 16-year-girl in Oregon named Kayla, who was shot to death by the highway, apparently by her 24-year-old boyfriend, who then shot and killed himself with the handgun, according to police. The 6-year-old girl in Cleveland —  her name was Navaeh, and her family called her "Nae Nae" — who somehow got her hands on what police said was the illegal handgun of her felon father, and shot herself in the face. The 18-year-old in Baton Rouge, Terrance, who was playing with a .357 Magnum; when it went off, the bullet missed him, and hit his 2-year-old brother, Travin, in the chest.

It's hard to miss how male the victims are: Out of 91 dead, 75 were men or boys. And the men were even more likely to be the ones pulling the trigger.

There's no way to count them all, but the press accounts of these deaths are sprinkled with deadly encounters fueled by drugs and alcohol. We didn't trace the race or ethnicity of victims or shooters for this project; though research indicates that blacks and Hispanics are more likely to be involved in gun violence. But the cases over this weekend were not limited to "urban" violence, with the deaths happening in cities and small towns and suburbs across many class and ethnic groups.

Looking through the deaths from just that one weekend, one wonders how many of these deaths could have been prevented by the gun-control and gun-safety changes that are being discussed in Washington. There are no easy answers, but one can draw an overall conclusion: Because the types of gun deaths vary greatly, so the solutions would have to vary as well.

David Hemenway, a professor of health policy and management at the Harvard School of Public Health, says it will require a national mindset shift to make big inroads into the number of gun deaths, similar to the change that occurred in how child abuse – a condition once considered so endemic that it couldn’t be addressed – was viewed after new laws against it were passed in the 19th and 20th centuries.

"If it was in your safety to have a gun in the home, people in public health would try to get you to own a gun," he said last month at a forum on gun violence sponsored by the Harvard School of Public Health and the Reuters news agency. "But what evidence we have is that it's against your self interest."

Improvement in mental health efforts, as proposed by the president, might make a difference, particularly in the 12 suicides and murder-suicides. But many of the cases will forever remain a mystery.

Warwick, R.I., Police Capt. Robert Nelson, who is investigating the murder-suicide of a longtime married couple on the MLK Day weekend, said the law enforcement system is set up to find and punish wrongdoers, not determine root causes: “We don’t have clear motive, and you know, you rarely do,” he told NBC News. “… As seen around the country, when someone kills somebody else then kills themselves as a result of that, you very rarely have any clear motive.”

In the Griego family massacre in New Mexico, as in the Newtown school shooting, there still is no clear understanding of what may have driven a young man to commit mass murder. Nehemiah Griego, 15, is facing murder charges in adult court. Police say the minister's son shot his mother and three younger siblings with a .22-caliber rifle as they lay in their beds early on that Saturday, then waited to shoot his father with the father's military-style AR-15 rifle.

What about the proposal to take "weapons of war" — or assault-type weapons —  off the streets, as Obama put it? Police are reluctant to give out details of the type of weapon used in a crime, because that's the sort of fact that they can use when interrogating witnesses and suspects. You'll see a lot of "unknown" for gun type on our map, and we don't have reliable information in most deaths about whether a gun was purchased or owned legally. There are several cases in which guns were not possessed legally.

The weekend of gun violence does leave an impression that few crimes are committed with the assault weapons whose legality is being debated in Washington. We saw one Detroit homicide where a witness said the gun was an AK-47, but police won't say one way or another. And Nehemiah Griego is said to have used a .22-caliber rifle, then a .223-caliber military-style AR-15 semi-automatic rifle.

Most of the killing, however, is done with handguns that are not on the political radar, one or two victims at a time, not crimes that depend on high-capacity magazines with more than 10 bullets.

“Certainly I’m not naive enough to say that if we were to ban military-style assault rifles and if we were to ban high-capacity magazines, that we’re not going to have killings or murders," said George Gascón, the San Francisco district attorney, an advocate of banning those weapons and high-capacity magazines. He was discussing the death of Daniel Colon, 44, who was killed with an unknown weapon on the morning of the inauguration, as he was walking home with his cousin from a bar where he had celebrated the football victory by the 49ers. "All we’re saying is that we can reduce the mayhem, and we can have greater control to make sure that the people that own weapons do so in a lawful fashion.”

Accidental shootings of children may be the most preventable, when children get their hands on guns that adults have not secured.

In McDonough, Ga., where the mother was asleep, the sheriff's office says the mother had let the children handle her .38-caliber revolver earlier in the evening, when it was unloaded. Sometime in the night, one of the boys loaded the gun.

The mother was awakened around 2:30 a.m. by a gunshot.

The mother's 14-year-old son had pointed the gun at his 15-year-old brother's chest and squeezed the trigger, the sheriff’s office said. The sheriff and the district attorney haven't released the names of the boys, and say they haven't decided whether to charge the brother with a crime. The sheriff's office said it didn't consider charging the grieving mother, because her gun was legally owned.

Many gun owners say they need their guns to be at hand and ready in case of an intruder breaking in during the night. "You try to look at the science," Hemenway, the Harvard professor, said at the gun violence forum. "There's no evidence at all suggesting that having the gun that you can get within two seconds matters more than the gun you can get within 10 seconds. ... There is a huge amount of evidence that having an unsecured gun leads to all sorts of death in the family."

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Looking at the gun deaths across the land, on just one weekend, is a reminder how ingrained the gun culture is in America, a large part of the story the country tells about itself, especially in the way its young men find identity.

Consider Jason "Cowboy" Monson, the freshman from the University of Idaho who went down to the police station to get his gun back.

On Friday, just before our weekend clock began, Jason's roommate spoke with his resident adviser in the dorm, saying he was afraid because Jason was keeping his Desert Eagle handgun under his pillow.

Jason was raised on a small horse farm in Middleton, Idaho, hunting and fishing, playing football for a Christian school. He was raised around guns. Jason's father is a county sheriff's patrol sergeant, and his mother is a former Boise police officer. (His parents did not respond to a request from NBC News for an interview.) Jason won a national speech competition with 4H, and was studying communications. He was also in the Air Force ROTC and hoped to serve his country. He had a new girlfriend and a sense of humor, and posted a lot of funny stuff on his Facebook page.

His online summary of himself was unassuming: "im a total cowboy. I hunt cowboy mounted shoot and drive an old ford diesel. Ive broken several bones and most recently chainsawed my foot, that was a great two months, insert sarcasm. I own several guns and will be in the ROTC at the u of I this fall. any questions message me."

Family photo

Jason Monson aims a blank pistol at the camera. Jason, who grew up on a small horse farm in Idaho, was active in Cowboy Mounted Shooting, which uses blanks.

Cowboy Mounted Shooting looks like a lot of fun. (Watch a primer on YouTube.) The riders train skilled horses and compete on an obstacle course, wearing a Western long-sleeved shirt and a cowboy hat and shooting guns loaded with powder cartridges--blanks--at ballooons. Jason had already won a couple of belt buckles. One of his fellow competitors described him as "very nice, respectful, personable and outgoing." It's a great sport for someone who likes people, horses, and guns.

When the roommate reported the gun, Jason was not at the dorm. The school called the city police, and an officer came and took the gun away. The police chief in Moscow (for non-Idahoans: that's "MOS-ko"), David Duke, said there was no hint that Jason had made any threat against anyone, and Jason wasn't in a whole lot of trouble.

After all, this is Idaho, where guns are freely allowed with no registration, and one can openly carry a gun without any permit. Jason had violated no criminal law by bringing his handgun to his dorm room, the police chief said. It was against the school rules to have it there — students have to keep their guns in the central gun locker provided by the school. Jason could have faced student judicial charges, but it wasn't a criminal matter.

When Jason got back to the dorm, his roommate had been moved to another room, and Jason was told that his gun had been confiscated. He called the Moscow police about 10 p.m. to get his gun back, and the officer asked him to come down to the station. He came down about 1 a.m., and the officer said he could have his gun, but not until Tuesday, after the MLK holiday, so he'd have a chance to lock it up at school.

At 8:46 a.m. local time Sunday morning, just as the Obama family was participating in a day of service by fixing up an elementary school in the nation's capital, Moscow police got another call from the University of Idaho, from the same dorm.

One of Jason's suitemates had found him, shot in the head, next to notes he'd written to his family.

Idaho has one of the highest rates of suicides in the country, mostly from guns. It also was the only state in the union without its own certified hotline with counselors trained in suicide prevention; a hotline opened in November, but it's open  only Monday through Thursday, 9 to 5. Chief Duke says he gets a call about suicide on campus every couple of years or so.

It turned out that the Desert Eagle .45 was not Jason's only gun. Sometime in the night, he'd gone out to his pickup truck for his Smith and Wesson Model 66 .357-caliber revolver.

'Flashpoint: Guns in America,' an NBC News special report 

In his obituary, his parents took the opportunity to plead against gun control: "Let us drag the evil hiding in the darkness of the most dangerous places on earth: Gun free zones."

Jason's photo with his obituary shows Cowboy Monson with a big grin, wearing a black hat and astride a reddish-brown horse at a canter. Jason is looking directly at the camera, where he is pointing his blank pistol.

That image is the profile photo atop his Facebook page, too, now and perhaps forever, along with the cover image of two semi-automatic rifles criss-crossed over the U.S. Constitution.

Read Part 2: The faces behind the numbers: Six victims of long weekend's violence

 Also contributing to this story and map for NBC News: Daniel Arkin, Meredith Birkett, John Brecher, David Friedman, Kriss Chaumont, Tracy Connor, Polly DeFrank, Matthew DeLuca, Miranda Leitsinger, Shezad Morani, Lisa Riordan Seville, Jonathan Sweeney and Lisa Wilkins.

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