For John Helfert, the problems started with the mortar shells screaming into the Abu Ghraib prison compound, the explosions sending furious shock waves.
"You don't feel like there is any place to go," said Helfert, then a Marine lance corporal in an infantry unit at the infamous prison. "You are sitting in a building or a tower, not knowing where the mortars are coming from. You feel like you are going to die."
Then there was the stress from the patrols escorting convoys through the deadly Sunni triangle. Even if under attack, rules of engagement prevented U.S. forces from firing on targets they could not positively identify as the enemy.
Like many people in the armed services, Helfert was reluctant to seek help.
"People keep things built up," he said. "They are too strong for this. They don't need help."
By the time he left the service in 2008, Helfert said he was suffering from depression and Post Traumatic Stress Disorder that strained his marriage and nearly ruined his life.
"I had road rage really bad," said Helfert, 31, a full-time student at the University of Tampa. "Things would bother me. Dogs barking. Helicopters flying. Planes from MacDill."
The stress got so bad that last October, he began thinking about ending his life.
Once every 36 hours, a service member commits suicide, according to the Department of Defense. In Tampa, the James A. Haley Veterans' Hospital sees about 20 patients a week identified as being at risk for committing suicide.
Statewide, more than 3,700 people identifying themselves as having been in the armed services committed suicide between 2004 and 2009, according to a study to be released in November by the University of South Florida's College of Behavioral and Community Sciences.
As the war in Afghanistan drags on, service personnel make multiple deployments and antipathy toward U.S. involvement abroad increases at home, suicides in the military have reached alarming proportions, military officials and health professionals say.
The issue gained national attention last month with the news of four suicides in a week at Fort Hood in Texas.
But for veterans such as Helfert, and those who continue to serve, it is a life-and-death struggle that has been taking place in the shadows for years.
"I was contemplating suicide," he said. "Self-medication was my way out of this. That was kind of when I knew I really needed to get help."
Hundreds died last year
With so many service people taking their own lives - 309 last year, 267 in 2008, according to the Department of Defense - the military has publicly ramped up its efforts to address the issue.
That's no easy feat in a culture of machismo where self-sacrifice is the order of the day.
Since 2003, the Army has been sending Mental Health Advisory teams to Afghanistan and Iraq to gauge soldiers' stability. The most recent findings, released last November, look at the situation in Afghanistan in 2009.
The study paints a picture of armed forces under increasing stress.
•Though individual morale rates were similar to 2005, unit morale rates were "significantly lower" in 2009.
•Rates of psychological problems - acute stress, depression or anxiety - were "significantly higher" in 2009 than 2005.
•Service members on their third or fourth deployments reported "significantly more" acute stress, psychological problems, marital problems and use of medication for psychological or combat-stress problems than service members in their first deployment.
Last year, the Army, in conjunction with the National Institute of Mental Health, launched a $50 million study to find new ways to prevent suicides. At a news conference, Gen. Peter Chiarelli, the Army's vice chief of staff, voiced a need for change by the service most affected by suicides.
"In the past, our training programs were ones of avoidance," he said. "We tried to avoid. And we then would treat or discipline soldiers. That has changed today. The goal is to assess, educate, train and intervene early in an effort to identify and mitigate issues before they can become significant concerns."
Despite efforts to improve mental health services, the military admits that it is having trouble keeping pace.
The Department of Defense Task Force on The Prevention of Suicide by Members of The Armed Services released a report in August offering a dire view of the military's ability to cope as suicide rates increase.
"The service suicide prevention program offices are not sufficiently staffed and resourced to meet the demand," the study found.
Maj. Ted Brown, preventive medicine physician at U.S. Central Command at MacDill Air Force Base in Tampa, said that as a headquarters operation, one of Central Command's key jobs is to ensure that those deploying have received training in combat operation stress and suicide prevention, and in identifying clues about stress and depression.
"Everyone is getting more training about being open," Brown said. "No one hesitates to talk about a broken arm or lung problems. We need to get to the point of discussing behavior health and mental health issues in the same way."
Road to recovery
The military's new openness, Helfert said, is exactly what service personnel need.
"Call someone from a veterans organization or go to the VA and get therapy," he said. "There is nothing wrong with that. It doesn't make you any less of a man to address your problem. It makes you more of a man."
Helfert's road to recovery began with a trip to Haley in 2007.
He didn't get better right away, though.
It wasn't until March, when he showed up at the emergency room, that he was able to take full advantage of Haley's services. The intensive treatment changed his life, Helfert said.
Though he did not take part in Haley's suicide-prevention program, Haley officials said Helfert's success story is exactly what they are trying to accomplish.
Haley has a comprehensive suicide-prevention team that augments the hospital's primary mental health services, said Carrie-Ann Gibson, a physician and chief of special programs.
People in the hospital's suicide-prevention program get a higher level of care, including enrollment in a crisis recovery group that meets three to five days a week, Gibson said. There are also individual services available.
Since Gibson arrived at Haley three years ago, the hospital has more than doubled its mental health staff to deal with the problems, going from 100 to more than 250 providers. The Post Traumatic Stress Disorder team is increasing from five to 15 clinicians.
Now, most of those identified as suicidal are veterans of the Vietnam War, Gibson said. But as the war in Afghanistan enters its ninth year, that will change, she said. In another decade, the majority of suicidal vets will have served in Afghanistan and Iraq, she said.
Helfert, who is studying finance at UT, is scheduled to intern with the Florida branch of Vets4Vets, a national group aimed at helping those who served in Afghanistan and Iraq.
The group, according to its Florida director, offers peer-to-peer counseling as well as an expense-paid retreat designed to help people such as Helfert realize they are not alone.
"I would like to reach out to vets," Helfert said. "I don't want to see service members killing themselves."