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In the days before Sgt. Sean Greany's suicide, he told his counselor at a Fort Belvoir, Va. wounded warrior unit conflicting stories about himself, he had an odd reaction to his medication and he altered his life insurance policy.
His mother, Petra Patterson, a registered nurse, said all the clues were in her son's medical files, and yet nobody put them together.
Speaking on a panel organized by the Tragedy Assistance Program for Survivors at the annual DOD/VA Suicide Prevention Conference in Washington this year, Patterson said, "I have learned the system is broken."
"I believe if Sean had been screened properly before and after his military service, his mental status would have kept him out or identified the need for immediate intervention," said Patterson, 53, of Hughesville, Md. "He could have been seen by a psychiatrist immediately upon his return who would have identified PTSD and depression earlier."
A spokesman for Northern Army Regional Medical Command declined to comment on the case.
Before he joined the National Guard in 2007, Greany had been a troubled young man: He grew up in an abusive home, and he acted rebelliously, Patterson said.
He returned home from a 2010 deployment to Afghanistan with a nonhealing clavicle fracture, in both "physical and mental pain," she said. He had been a combat engineer
In a wounded warrior unit at Fort Belvoir, Va., Greany was diagnosed with post-traumatic stress disorder and as a low suicide risk, and he received counseling, but he was never seen by a psychiatrist and diagnosed, his mother said.
One week, he told his counselor he was married, and the next week, he said he had a girlfriend, she said. One week, he said his mother was dead, and the next week, he said his mother had breast cancer.
The inconsistencies were never taken seriously, she said.
"When I saw his medical records and saw how inconsistent his stories were, I was furious," she said. "Sean was the perfect example for silent symptoms of suicide, according to his medical records. The signs were there."
She said she saw from his records that he had been delusional, anxious and impulsive and he suffered from sleep problems.
For his night terrors, he was prescribed antidepressant Trazodone for insomnia, his mother said. Yet Trazodone carries a "black box" warning — that antidepressant use carries an increased risk of suicide in children, teenagers and young adults — and she feels he should have been monitored more closely.
In the days after he began taking the medication, Patterson said he called to tell her, "Mom, this medication makes me feel weird." She urged him to stop taking it and see his doctor.
On April 22, 2011 — Good Friday — he died after ingesting a poisonous plant.
In the days before his death, Greany changed his life insurance policy. Despite his diagnosis of PTSD and as a suicide risk, nobody noticed. It should have been a "red flag," Patterson said.
"Sean cried out for help, but nobody wanted to hear his cries," she said. "He was just a number."
She said there are too many problems with the care of service members suffering from both physical and mental wounds.
"I have learned that men and women who risk their lives for us in their military service are coming home and feel misunderstood and betrayed by the very government they are pledged to serve," she said. "I have learned that when someone appears strong on the outside, they may be in incredible pain on the inside."