Army Capt. Rich Ducote's first brush with death came about 10 days before Afghanistan's Oct. 11 presidential election, when a rocket-propelled grenade exploded against the right front wheel of his Humvee, knocking him unconscious.

"It was just a large flash, heat. You felt the debris and stuff entering the vehicle," Ducote said. "Next thing you know, you're waking up and you hear crackling (of gunfire) all over the place."

With U.S. involvement in war in the Middle East nearing the four-year mark, the stories that Ducote and other returning soldiers tell are increasingly familiar to specialists in the stress associated with combat. With hard lessons learned from a relatively few but high-profile killings and suicides following war-zone duty, the U.S. military has ramped up efforts to counsel and treat returning war vets.

Ducote's second close call with death came less than two weeks after the first attack.

In another small-arms attack on one of Ducote's convoys, in the same creek bed less than a mile from the first attack, a rocket-propelled grenade slammed into another Humvee's windshield, breaking all the bones in a young lieutenant's face.

Ducote, 31, who was a Schofield Barracks company commander in Afghanistan with the 2nd Battalion, 5th Infantry, lost four soldiers during the yearlong deployment.

In a different theater, Cpl. Nathan Couey, 22, was clearing houses in Fallujah, Iraq, in November when two close friends and fellow Marines were killed as they entered a courtyard across the street.

Lance Cpl. David M. Branning, 21, died pretty quickly. Marines had Lance Cpl. Brian A. Medina, 20, in the street, and his flak jacket opened, but he was hit pretty bad, and died en route to medical aid, said Couey, now out of the Marines and living with his family in Mississippi.

It's the stuff nightmares are made of, and quite often are, for Hawai'i soldiers and Marines returning from combat.

LINGERING EFFECTS

The stories are told over and over, and the effects months later can be similar: sleeplessness, bad dreams, irritability and sometimes rage.

The smell of diesel fuel can return a combat veteran to the scene of a battle. There may be anxiety in traffic congestion on H-1 because of the prevalence of car bombers in Iraq.

The 25th Infantry Division (Light), in partnership with Tripler Army Medical Center, spent $4 million on a Soldier and Family Assistance Center at Schofield, where counseling and treatment is available to combat veterans, including Marines.

But efforts to address psychological issues begin before a deployment, with suicide prevention counseling and a mental health screening. They continue in a war zone, and are picked up again after returning home.

Last month, the results of a mental health team's assessment of treatment in Iraq pointed to progress.

"The report clearly shows that there is an overall improvement in the mental healthcare system in theater, but there is more work that needs to be done," said U.S. Rep. John McHugh, R-N.Y., at a Congressional hearing on military mental health.

A Defense Department-mandated second mental health check-up three to six months after a combat veteran returns — the first is required soon after arriving back home — is expected to start up later this month.

One survey showed 30 percent of U.S. troops said they developed stress-related mental health problems three to four months after coming home from the Iraq war, according to the Army's surgeon general.

About 4 percent to 5 percent, are diagnosed with post-traumatic stress disorder, or PTSD, a serious mental illness.

Maj. Stacy Bathrick, a Schofield Barracks spokeswoman, said per guidance from the Department of the Army, no statistics would be released on type and number of combat stress problems experienced by soldiers here.

MAY HAVE TO GO BACK

In Hawai'i over the past six months, 11,000 soldiers and more than 2,000 Marines have returned from war but now face a new stressor — repeat deployments.

The 1st Battalion, 3rd Marine Regiment from Kane'ohe Bay, which lost 50 Marines in Iraq, is in line for Afghanistan duty next year. The 3rd Brigade Combat Team at Schofield Barracks, whose 5,500 soldiers got back this spring from Afghanistan, also is expected to return to a war zone next year, possibly Iraq.

It's a new paradigm for a stretched-thin military, and Schofield Barracks — which had not deployed as a division since the Vietnam War — is working overtime to address the mental-health needs of soldiers.

Maj. Bryan Bacon, psychiatrist for the 25th Infantry Division (Light), said most soldiers grapple with whatever issues they have after returning home, and in several months, those issues pass.

Readjustment to civilian life from desert austerity, combat and wearing desert camouflage brings its own challenges.

"It's pretty normal when you come back to feel a little nervous or a little angry, a little sleepless," Bacon said. "They are changed people. For sure they are changed people, but they return to a new baseline or a new kind of norm."

A small percentage either do not adjust or their adjustment is very poor, he said. That includes those who suffer PTSD, he said.

Those with PTSD may experience a life-threatening event, and then re-experience that event, usually through nightmares or flashbacks. Triggers can include cars backfiring, or the smell of diesel fuel — which may be a reminder of a roadside bomb explosion.

With the brain on overload, the body may express the stress with shakiness, insomnia and anger, Bacon said. The most serious and common consequence of PTSD is drug and alcohol abuse, followed by depression and the break-up of relationships.

"I run the mental health clinic for the soldiers, and they have serious problems, they have real PTSD, they have real marriage problems, and they have real drug and alcohol problems," Bacon said.

Bacon said there have been no soldier suicides. Elsewhere, those issues have brought tragic results. Earlier this month, a Fort Carson, Colo., soldier killed his wife and took his own life after returning from Iraq. Authorities said the woman had told her husband she had been having an affair.

STIGMA OF STRESS

Ducote, from Dunwoody, Ga., and now at Fort Shafter with U.S. Army Pacific, said he initially had to deal with quite a bit of stress after experiencing the two attacks in Afghanistan.

"It was tough sleeping at night, I'm not going to lie to you, but it made us stronger as a company because we were more alert, more aware," he said.

He credits the thoroughness of the Army's counseling. Even at remote Forward Operating Base Cobra in Uruzgan Province north of Kandahar, chaplains and mental-health experts made regular visits.

"I had a chaplain who stayed — I couldn't get rid of the guy — whenever something happened (like we) lost a soldier to an IED (improvised explosive device) or something like that," Ducote said.

A big obstacle to treating combat stress is the stigma attached to it. For soldiers in a warrior culture who are supposed to act unflinchingly in combat, stress and problems associated with it are sometimes misconstrued as weakness.

Soldiers who make their problems known can be yanked from frontline units. Knowing that, some won't seek help. That's part of the reason chaplains and counselors actively seek out soldiers who have gone through trauma.

SHARING EXPERIENCES

Couey, the Hawai'i Marine, experienced the loss of two good friends on the second day of door-to-door clearing operations in which the 1st Battalion, 3rd Marines were involved in Fallujah, Iraq.

On Oct. 30, the battalion lost eight Marines in a suicide car bomb attack. More would die in Fallujah, and on Jan. 26, a helicopter crash in western Iraq claimed the lives of 26 Hawai'i Marines and a sailor.

"I know that everybody had little different things like loud noises would make you jump," the Mississippi man said. "One buddy, after leaving Iraq, was at the airport and a plane went over and he ducked."

As the Fallujah offensive began in early November, Couey's pregnant wife was moving from Maryland to Indiana. The couple's twin boys were born prematurely on Dec. 9, and Couey was sent home on emergency leave.

Neither he nor his wife felt the need to seek mental health counseling during the stressful time.

"No, I don't think I ever would," he said. "I mean, they're really not going to know what you're talking about."

What's worked for Couey, now out of the Marines, is keeping in touch with fellow unit members and talking to them. When he was on leave, Couey and four other Marines met in Mississippi and drove to Arlington National Cemetery to visit Branning and Medina's graves. They also visited with Branning's family in Baltimore.

First Sgt. Peter Siaw, 32, who was with Bravo Company in Iraq and now is with Weapons Company, said the Marines, too, conducted a full-on mental health effort, with checkups before, during and after deployment.

"So when a young Marine comes and says, 'I'm having difficulty,' no one's going to turn him away and say, 'Ah, you'll be all right,' " Siaw said, "because we know what it was like to go through the streets (of Fallujah) every day, clearing 70, 80, 100 houses."

Reach William Cole at wcole@honoluluadvertiser.com.