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Combat stress: The war within

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The hidden cost of sending troops into combat.
• Flashbacks, nightmares or frightening thoughts -- especially when exposed to something reminiscent of the original trauma.

• Emotional numbness, sleep disturbances, depression, anxiety and irritability or outbursts of anger.

• Feelings of intense guilt are also common.

Source: National Institute of Mental Health
• Interactive: Who's who in Iraq
• Interactive: Sectarian divide
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Department of Defense

(CNN) -- Almost two out of every 10 U.S. troops who have faced combat in Iraq may return with serious symptoms of depression, anxiety or post-traumatic stress disorder, according to an unprecedented study.

Sgt. Danny Facto of the Army's 10th Mountain Division suffered those invisible scars of war.

After seeing comrades killed, the 24-year-old infantryman experienced troubling emotional and mental changes.

"You're just always intense. You're always super serious and you lose your temper over little things and you're not the same person who deployed," Facto said.

The first-ever wartime study of the mental health of combat troops appears in Thursday's edition of the New England Journal of Medicine. Previous studies of war veterans have been conducted years after combat ended.

Four combat units -- three Army infantry units and one Marine unit -- that fought either in Iraq or Afghanistan participated in the new study. The 6,201 troops filled out anonymous questionnaires before, during and after deployment.

The study found 17 percent of those who served in Iraq met the criteria for major depression, anxiety or post-traumatic stress disorder -- or PTSD. Eleven percent who served in Afghanistan met the criteria.

But even worse, the study found, was that less than 40 percent of those afflicted by PTSD sought help.

The Department of Defense requires that every service member be briefed on mental health before, during and after deployment.

There are also an unprecedented number of treatment programs available. But some say that is not enough.

"You can't just say that I've got a hundred programs, therefore, I've done my job," said Steve Robinson, executive director of the National Gulf War Resource Center. "This study indicates that the sickest veterans who need the most help won't go."

Ninety percent of those posted to Iraq reported being shot at. A high percentage also reported killing an enemy combatant, or knowing someone who was injured or killed. About half said they had handled a body.

On his second day in Iraq, Staff Sgt. Georg-Andreas Pogany saw an Iraqi body that had suffered severe trauma, and he suffered what he thought was a nervous breakdown.

"I wasn't functioning. I was having physical symptoms. I was having a behavioral reaction," he recalled.

After struggling through the night, he said he decided to tell his superior officer out of fear that "if we do go out on a patrol and I do freeze up, that could have consequences too."

But instead of being given help, he was told to reconsider for the sake of his career, he said.

"The message was: 'Hey, you're a coward. You're acting like a coward.' "

A translator attached to the 10th Special Forces Group, the 32-year-old Pogany was sent back to the United States, where he was charged with cowardice. That charge eventually was dropped, but his record is still uncertain.

"My career is probably at an end. I've had my security clearance revoked. I'm still struggling to get things set straight," Pogany said.

He hopes that by speaking out he can help other war veterans.

"The most important thing is that trauma, whether it is experienced in combat or anywhere else in life, needs to be looked at as an injury to the mind. And an injury to the mind needs to be treated just like an injury to the leg, whether you have shrapnel wounds or gunshot wounds," he said.

In Facto's case, a positive attitude toward treatment displayed by his commanding officers, family and fellow troops helped him overcome any stigma and get into the group therapy he needed.

Sgt. Danny Facto benefited from treatment for post-traumatic stress disorder after returning from Iraq.

"When I go to group and I talk with guys who are just like me it helps a lot, because I can discuss with guys that have been in combat, guys that have been shot at, guys who have lost friends in combat, guys that have killed other people," he said.

Facto said therapy has made him a better father, soldier and husband.

"When I came back, I was me, but I was different because of my experiences," Facto said. "Mental health and therapy really helps to understand everything I've been through."

Despite the military's efforts, legitimate concerns about stigmatization and loss of career advancement remain -- a great price to pay, especially for career military officers.

"Soldiers are concerned that coming to see us might harm their careers," said Maj. Paul Morrissey, chief of mental health services at Fort Drum in New York. "I can say to them sincerely, honestly that not coming to get some assistance will harm their careers."

CNN's Sanjay Gupta contributed to this report.

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