Gregg Zoroya and Tony Leys

USA TODAY Network

“The rest of the morning was spent picking up body parts, still warm, in perfect condition, like they had just fallen off the owner. My Marines were crying and I yelled at them, calling them demeaning names and to man up. This day caused so many feelings & emotions in me that I wrote my dad about the event and how much it was tearing me apart. We never talked about it, but one year later, he died and I found it in a safe under his bed. Nothing else was in the safe. He took it to the grave. I felt so guilty and ashamed that I told him. I thought that I caused the stress that led to his fatal heart attack.”

IOWA CITY — Brandon Ketchum was on a rescue mission on a rainy morning in July when he pulled into the parking lot of the VA hospital here. Strolling into the towering building, Ketchum cut the same trim figure, with perhaps a few extra pounds, that he carried in the Marine Corps when he twice deployed to Iraq during the height of the insurgency, then served in Afghanistan with the Iowa National Guard.

Except now, at age 33, the blue-eyed veteran wore a full red beard that his 4-year-old daughter loved to cut with an electric razor and he had needle tracks on his left arm from the heroin he'd been shooting up for a month.

"I have run my life out of control to the point where I can't live it anymore," Ketchum had jotted on a notepad back at his home in Davenport, Iowa.

But a part of him wanted to live, and that's why he was seeing his psychiatrist at the Department of Veterans Affairs.

This is the story of one combat veteran's desperate fight against the self-destructive urges pulsing through a generation of men and women who served in Iraq and Afghanistan. Through a series of interviews, an examination of a thousand pages of medical files and a review of Ketchum’s extensive journals, USA TODAY gained rare insight into what he called “a war within myself.”

On July 7, the day he saw psychiatrist Anthony Miller, agency officials in Washington released preliminary findings from a sweeping analysis of suicides among veterans. Scientists pored through 50 million death records from 1979 to 2014, counting every suicide. There were 7,403 in 2014 alone. They learned that, on average, 20 veterans commit suicide each day.

Donald Trump called the findings shocking. President Obama told a Disabled American Veterans convention in August that the suicide trend was a national tragedy. "We all have to do better," he said.

The VA analysis found that most suicides are among its largest constituency of veterans: those from the Vietnam era. But the highest rate of suicide was among younger veterans who served during the recent wars in Iraq and Afghanistan — Ketchum's generation. Veterans ages 30-39 committed suicide at rates four times the national average and those 18-29 at nearly six times that average.

Caitlin Thompson, a clinical psychologist who runs the VA's suicide prevention program, recalled the wrenching experience of losing three veterans to suicide. They were patients of hers and a team of health care workers.

"That's why I dedicated my life to veteran suicide, because I see those three young men over and over and over," she said. “We know there is hope … we know that people do get better.”

The Iraq and Afghanistan wars were unique in physical and emotional demands. Because the wars lasted so long, large numbers of troops were required to serve multiple deployments that added up to years of cumulative combat duty. Ketchum did three tours. Others have done more. The result was veterans with a complex roster of ailments. Ketchum, who was a combat engineer, suffered from service-related injuries to his knees and back, as well as traumatic brain injury, post-traumatic stress disorder, depression, substance abuse, headaches and ringing in the ears. He had a team of people supporting him at the VA in Iowa, a coordinated effort that is a hallmark of the agency.

One of the team members was Miller, Ketchum's psychiatrist. On that Thursday morning last July, after 10 minutes, Ketchum stood up, thanked the doctor for his time and walked out.

Miller pursued him into the parking lot and rapped on the hood of his Hyundai to get the veteran to stop. Ketchum raised his arms in a shrug, as if to say, "What's the point?" and drove off.

It was hard to understand Ketchum's despair. He adored his daughter, Layla, and had a three-year relationship with Kristine Nichols, a social worker who cared deeply about him. He had come out of the military respected and loved by his combat brethren. "He had a lot of genuine goodness in his heart," said Ethan Driscoll, Ketchum's platoon commander in 2006. "He took care of people and wanted to do the right thing."

"Even people that outranked him looked to him for advice because he’d been there, done that," said Shane Bowman, who served with Ketchum in Afghanistan in 2010 and 2011.

Strife didn't end when Ketchum put the uniform away. "I came home from war only to become lost in the fog of another war," he wrote.

Brandon Michael Ketchum was born in Killeen, Texas, the son of Sgt. 1st Class William Ketchum, who was assigned to nearby Fort Hood, the Army's largest military installation. Brandon’s parents split up when he was 5, and he only occasionally saw his father. He spent nearly all of his childhood growing up in Baraboo, Wis., next door to the Wisconsin Dells, a tourist magnet known for scenic Wisconsin River bluffs, amusement parks, waterslides and family-style restaurants. It was a place of dreams for a growing boy, offering hunting, fishing and skateboarding.

His mother, Beverly Kittoe, a hairstylist, struggled raising Brandon and his younger brother, Brad. When her older son grew rebellious, chafing at school and study, and she discovered marijuana in a suitcase one day, she'd had enough. Brandon, then 14, was sent to live near Des Moines with the father he hardly knew, who was by then retired from the Army and struggling with his own issues of substance abuse.

It was a tearful shock for the teenager to be exiled this way. Within a year, state officials pulled him from William Ketchum's home amid allegations of child abuse, and the boy went to live with a woman his father had been dating, a social worker who had alerted authorities to what was happening between father and son.

Years later, during therapy at the VA, Brandon Ketchum often returned to this troubling period in his life, living with a father who was stern and emotionally detached, but with whom Brandon longed to make a connection.

Brandon ultimately went back to Baraboo and his mother, who would remarry. He drifted after earning his diploma from an alternative school. A skateboarding accident left him with torn knee ligaments requiring two painful reconstruction surgeries, and Brandon began abusing prescription medications and worse. His younger brother found syringes in the garbage, and Brandon admitted he had tried heroin.

The father's influence still held sway, and Brandon, always compelled to do better, followed him into the military, enlisting in the Marine Corps in 2004 at age 21. "That was kind of what he thought was going to be the best thing for him. And I agreed," Kittoe said. "He just felt this was his calling."

Like so many other parents of children entering the military during those war years, Kittoe marveled at how Brandon was transformed and was blown away by the boot camp graduation at Camp Pendleton, Calif. "It was absolutely amazing," she said.

He was stationed for six months in South Korea, working as a camp guard at the Marine Corps' Camp Mujuk near the Sea of Japan. The insurgency was gaining ground in Iraq, and by February 2006, Ketchum was in combat, often riding in the most dangerous place for route clearance missions — the lead truck. He was part of Charlie Company, tasked with locating roadside bombs, a weapon causing the greatest number of U.S. casualties. Charlie Company operated along roadways between the violent cities of Ramadi and Fallujah.

The company's commander, Scott Zimmerman, today a lieutenant colonel, said its motto was "We roll deep," and the Marines cleared 92 bombs in seven months. Ketchum earned a Combat Action Ribbon. The Marines worked out of armored vehicles, but there were detonations that left them stunned.

At the time, military medicine barely understood what exposure to a bomb blast could do to the brain and how rest is required to allow recovery. There were insufficient field resources to deal with increasing cases of post-traumatic stress disorder — or PTSD, the chronic anxiety and memory-flashback illness that service members suffer after terrible events.

Troops showing signs of PTSD were often urged to buck up and stay on mission. The challenges of fighting an insurgency sometimes left Charlie Company in emotionally troubling circumstances that no training could contemplate.

Every member of the company remembers Oct. 14, 2007, during Ketchum's second tour to Iraq.

"I was always ashamed about the event," recalled Driscoll, Ketchum's platoon leader at the time. "It was like combat, but it wasn't like combat. I mean, it wasn't what I thought it was going to be. I thought bad guys were going to shoot at me. We were going to shoot back. And we'd have these cool war stories."

By that time, Ketchum had been promoted to sergeant and team leader and was acquiring the skills to be tough, calm and steady in times of chaos, Driscoll said. "He looked like an experienced Marine."

On Oct. 14, insurgents detonated a vehicle bomb near the home of a police chief who was inside with his extended family. It was a slaughter. The Marines witnessed the attack and rushed to cordon off the area.

This was the attack Ketchum wrote about to his father.

"My vehicle was positioned closest to the blast, front row seats to the carnage," Ketchum wrote in his journal during therapy. A car drove toward the Marines, and Ketchum's men were ready to fire, but something told him it wasn't part of the attack, and he had his men stand down. In fact, it was a family trying to rush a young boy with mangled legs to medical care. The boy died before he could receive treatment.

“I let the father use my shovel to bury him, and the mother carried what was left of him across the road and buried him atop a hill,” Ketchum wrote.

Driscoll remembered finding a dead young girl, maybe 4 years old, lying on the ground with her eyes open. "She had blue eyes," he said.

In the years to come, the military would learn to send chaplains or mental health counselors to meet with troops exposed to such horror. But not yet. Charlie Company went on to the next mission.

By his third combat tour, Ketchum was 28 and showing signs of physical and emotional wear-and-tear — much like others of his generation subjected to multiple deployments. He had left the Marine Corps in 2008 after a standard four-year term, and within a few weeks, he joined the Iowa National Guard as a combat engineer. His unit was unexpectedly called up for duty in Afghanistan in 2010. Ketchum would be back doing route clearance in eastern sectors of the country.

He had fallen hard down a steep slope while training in California's Sierra Nevada. He was carrying a heavy cement saw, and the fall re-injured his bad left knee. Pain medication became an on-again, off-again part of his life. Six months into the Afghanistan deployment, Ketchum had a seizure and collapsed in his barracks at the U.S. military base in Bagram.

He was evacuated back to the USA, bitter and ashamed to leave his squad. Within a month of coming home, he married a young woman who was pregnant with his child. Layla was born in October 2011. But it was a tumultuous period back from war. He began abusing drugs for his chronic pain, his marriage was quickly disintegrating, and his wife found him one night with a gun barrel in his mouth. Before the year was out, the Army sent Ketchum to a civilian detoxification center in Kentucky, where he was under care when divorce papers arrived from his wife.

Ketchum was transitioning from combat soldier to civilian, and it was uncertain terrain, marked by redemptive periods of sobriety and desperate times of guilt, shame and drugs. The cycle repeated over and over.

He received a medical discharge from the Army National Guard in July 2013.

"I didn't decide to leave the military. The military told me I had to leave," he explained to a classroom of students during a talk that was videotaped. "I was medically and mentally unfit. I have nine screws around my spine, diagnosed with post-traumatic stress and traumatic brain injury."

He said his comfort zone "for so long was being behind a rifle or being in a big armored vehicle. Being home, walking down the street, going shopping, staying at my house — that was well outside my comfort zone," he said. "I missed the battlefield more and more, and that consumed my mind."

The same year of his discharge, Ketchum met Kristine Nichols through a free online dating service called Plenty of Fish. She thought he was funny and unassuming, and on the first date remarkably candid about struggling with addiction, living with nightmares, being afflicted with PTSD and coping with a body that, at age 31, felt broken and painful.

"I'm a social worker," she said, "so I know a lot about mental health and a lot about substance abuse. I know those things don't mean someone's a bad person."

He used his GI bill to pay for studies at a community college but couldn't relax during lectures and would forget when to be in class. He tried construction but missed too much work. In September 2014, he was stopped for driving under the influence, and the next month, he overdosed on heroin and Xanax in an apparent suicide attempt, according to his medical files. Through it all, Nichols supported him but warned that their relationship depended on his choosing to live drug-free.

Ketchum entered a VA detoxification center in Minnesota and stayed there for weeks. Word arrived that a Marine buddy, Brandon Baldwin, had shot himself to death in his home outside Charleston, W.Va. Ketchum began to fill out journals about his life choices, his father and what happened Oct. 14, 2007. "The event has caused me to see myself as a failure, remain on guard or hyper-vigilant, powerless or not in control and distant from many people who I care about deeply," he wrote.

He emerged from treatment, as before, focused and optimistic. "I feel like I'm in a much better place," Ketchum told a VA therapist. He joined Alcoholics Anonymous, loved Nichols and was seeing Layla six hours a week, hoping to persuade a judge to allow more time with his daughter.

But depression returned, along with heroin, in January 2015. By early February, Nichols found him overdosed once again and performed CPR, calling paramedics. Ketchum told therapists that he regained consciousness to see paramedics over him, saying he nearly died. The incident frightened him deeply. He was admitted to a private hospital in Davenport, Iowa.

This was a period of turmoil at the Department of Veterans Affairs. Congressional hearings had found evidence the year before of staff members covering up widespread instances in which veterans waited too long to see a doctor or receive therapy.

Officials within the VA argued that, notwithstanding delays, medical care for veterans was excellent. This seemed to bear out for Ketchum. A team of health care workers managed his treatment, including a psychiatrist, psychologist and substance abuse counselor, and, when necessary, he was referred for treatment to the University of Iowa Medical Center. He and Nichols were in couples counseling. Ketchum attended several types of group therapy, including for anger management and relapse prevention. Nichols enrolled in a VA caregiver program to help Ketchum and received training and a stipend. Agency social workers conducted home visits to see how the couple was managing. Whenever Ketchum didn't show up for an appointment, someone called to check on him.

He moved into Nichols' home in Bettendorf, Iowa, near Davenport, in 2015. They shared the house with a husky named Chaos, a pit bull named Havoc and three cats. While his license was suspended after the DUI arrest, she drove him to therapy on her day off and sat with him during counseling. All this, and she was working full time as a social worker doing in-home visits with high-risk families and waiting tables on weekends for extra money.

Ketchum entered a long period of staying away from heroin, although he still used marijuana, which he said calmed him and helped with chronic pain. Through therapy, Ketchum explored feelings of abandonment, mistrust and a sense of being "defective" or a failure — feelings that tended to leave him "stuck" emotionally, according to his medical files. "It was hard for him to ever see the positive in himself," Nichols recalled. Ketchum's VA substance abuse counselor, Darrel Kirby, warned how heroin euphoria could mimic a satisfying sense of accomplishment, but there would always be the inevitable withdrawal steeped in despair.

Ketchum avoided the drug and made plans for the future. He drew peaceful satisfaction working and crafting in wood. He and Nichols turned a shed in her backyard into a workshop. He created decorative display boxes, cutting boards and shadow boxes. He loved using Purpleheart wood, which has a straight grain and a tendency to grow darker with age. His dream was to attend a woodworking trade school in St. Louis and become a craftsman, and he drew up a three-year plan. The crux of that future was more time with Layla, and, in preparation, he and Nichols repainted a room in her house in pink and purple in September 2015 and bought bunk beds.

By January 2016, Ketchum felt better about himself. He earned $3,100 a month in disability from the VA and $1,200 from Social Security, $600 of which went to child support for Layla. "He expressed optimism for his future with his girlfriend, his role as a father, his physical health goals and starting his woodworking career," Kirby wrote in notes. Ketchum signed up to be a member at Nichols' gym, began volunteering three days a week at an assisted-living home to play games and talk with residents and took parenting classes. He tapered off using the detoxification drug suboxone.

By February, he had gone almost a year without using heroin, and in March, he graduated from intensive outpatient therapy for substance abuse. He got his driver's license back and reached out to Army buddies for a dress uniform to wear to an upcoming child-custody court hearing. During a group therapy session in March, he and other veterans repeated the serenity prayer out loud:

"God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference."

A routine drug test by the VA on April 12 showed Ketchum free of drugs.

Something happened later that month. There was an episode with his family back in Wisconsin. Ketchum wanted to come visit his stepfather, who had undergone open-heart surgery, but was told visitors were not a good idea. Then Ketchum learned one other family member was there so that his mother could go back to work. He felt rejected. Ketchum also thought increasingly that he was becoming a burden to his girlfriend, therapist Kirby wrote in his notes.

During April and May, Ketchum began missing group and individual therapy sessions. Late on the night of June 14, he called the VA suicide hotline and said he was thinking about ending his life. He showed up for counseling the next day complaining about a deep depression. He'd stopped volunteering his time and exercising.

A VA case manager called Ketchum on June 24 to check in. The veteran admitted he was having severe heroin cravings and was severely depressed. "Patient stated he is in a really dark place right now," the case manager wrote.

Psychiatrist Miller followed up with a phone call and arranged to have suboxone delivered to Ketchum, so he could start using it again. VA social workers visited Ketchum and Nichols in her home the same day for a routine assessment. She admitted feeling overwhelmed because of a slew of issues, including buying her home from her ex-husband. What Nichols didn't tell them was that her boyfriend was using heroin again. Nichols was worried that if word got out, it would ruin Ketchum's desperate attempts to see his daughter.

Nichols did decide to contact the VA several days later, urging that someone be appointed to handle Ketchum's personal finances. He was spending thousands of dollars, and she was sure it was on drugs. He kept promising her he would stop, but Nichols caught sight of his left arm while he was driving and saw needle marks. During that Fourth of July holiday, she told him to move out. Nichols didn't see it as a breakup, but she hoped to use her demand to finally force him to get help. They spoke or texted every day, and he promised her he wouldn't do anything to harm himself.

In fact, the Tuesday after that long weekend, Ketchum began drafting a suicide note. "Today is the day, I give up and bring all this suffering to an end,” he wrote.

He didn't act, however. He was to meet with Miller on Thursday, July 7. If he could be hospitalized, Ketchum felt this would deliver him from cravings and despair as it had before.

When Miller and Ketchum sat down that morning, the veteran confessed about using heroin since early June and asked to be admitted. The psychiatrist disagreed about hospitalization. According to his notes, Miller said inpatient treatment rooms for detoxification were full, and it was more appropriate to treat Ketchum on an outpatient basis. Ketchum told him "he can't do it outpatient," Miller noted.

The psychiatrist brought up the issue of someone overseeing Ketchum's personal finances and asked what the veteran thought about that. The question ended the session.

"My thoughts about it don't matter," Ketchum snapped. "They are going to do what they want to do. They won't let me come in the hospital to get help, but they'll take my money."

He got up, thanked Miller for his time and walked out. Miller didn't have a chance to do a suicide assessment.

Clearly concerned about how the session ended so abruptly, the psychiatrist followed Ketchum to the parking lot, then called Ketchum within a half-hour, leaving a voice mail. The psychiatrist assured him that he wasn't ready to recommend taking away Ketchum's access to his money.

"I didn't want you to run away thinking that we were necessarily going to be doing that," Miller said.

The doctor repeated that no hospitalization was necessary, then seemed to soften on that: "I think we can do it on an outpatient basis. If not, we can talk about what other options we can pursue."

By the time Ketchum saw Miller, he'd already filled three pages with thoughts about ending his life. That night, he texted his mother in Wisconsin about his bitterness toward the VA: "The blood is on their hands now."

His mother felt that his daughter and girlfriend gave him much to live for, so Kittoe assured him by text that help was out there and she would call him the next day. Around 1 a.m. Friday, July 8, Ketchum came by Nichols’ home in Bettendorf, telling her by text that he wanted to get something to eat. She had gone to bed early.

"I remember him standing in the doorway of the bedroom, and that's about all I remember," she recalled. "I'm pretty sure he said, 'I love you.'"

Then he left.

A little after 2 a.m., Ketchum filed an angry rant about the VA on a Facebook site frequented by veterans. "Not only did I get a NO, but three reasons of no based (on) me not being 'f----- up enough,'" he wrote. "They gave up on me, so why shouldn't I give up on myself?"

Sometime that morning, in an upstairs bedroom of his wood-frame home in Davenport, Ketchum gathered photos of himself and Layla. He sat down on the floor with his back against the wall and put the pictures near him. He drew close a fleece blanket embroidered with images of his girlfriend and daughter — a Christmas gift from Nichols. He reached for a .45-caliber pistol he had reported stolen months before.

The 911 call arrived shortly before noon July 8.

The woman on the line was sobbing. The 911 operator walked her through threshold questions — address, phone number, name, Kristine Nichols — that were achingly banal in the context of what was about to be said:

"My boyfriend shot himself. He's already dead."

Later that day, Ketchum's cellphone rang with another call from his psychiatrist.

"Hey, Brandon, it's Dr. Miller. I wanted to check in on how you're doing."

In the weeks after the suicide, Brandon Ketchum's family demanded answers from the Department of Veterans Affairs about why his request for hospitalization was turned down. "We want to know that there's something that can be done so that hopefully this doesn't happen again," Kittoe said. She and Brandon's brother, Brad, and Nichols met with Miller at the Iowa City VA and were provided copies of Ketchum's medical records. Democratic Rep. David Loebsack of Iowa, wrote the VA seeking answers.

USA TODAY obtained copies of Ketchum's medical records and asked Patrick Lillard, a psychiatrist and former clinical director of the Army's largest inpatient substance abuse program at Fort Gordon, Ga., to review them.

Lillard said he would have hospitalized Ketchum. "For this guy to come and ask for help, it's like he's begging. He knows he's in trouble," Lillard said.

Ketchum's medical records were rife with clues supporting inpatient treatment, Lillard said. The veteran had been hospitalized on five occasions and twice attempted suicide. On more than one occasion, the VA had deemed him a high risk for suicide. He was pushing away his support network, telling a VA social worker days earlier that his relationship with Nichols had ended. In the weeks leading up to the suicide, Ketchum complained repeatedly about severe depression, and he admitted using Valium or Xanax bought on the street, sedatives that can exacerbate paranoia or suicidal thoughts.

Miller should have assumed the worst and called security when Ketchum walked out of his office, Lillard said. "I give him credit. He followed him to the parking lot. But the patient didn't want to have anything more to do with him."

Miller explained some of his thinking in his notes. Detox was normally handled on an outpatient basis. Miller acknowledged "a couple of significant risk factors for suicide" — Ketchum's previous attempts, life stress and substance abuse — but noted that Ketchum denied harboring suicidal thoughts during a recent telephone assessment. Miller wrote that there was only a "moderate risk" of suicide.

The VA declined to allow an interview with Miller for this story. Harold Kudler, chief consultant for mental health services for the VA, defended the psychiatrist's actions. He said Miller conducted a full and fair assessment of Ketchum, balancing signs of suicide risk and mitigating factors and reached a reasoned conclusion. Despite Miller's assertion that there were no inpatient rooms available, Kudler said that was not a factor and that the VA would have found a place for Ketchum in a private facility if necessary.

"Everybody would like to run this tape backward and make it end differently," Kudler said. "But this man did an assessment. He reviewed the chart very carefully. He knew the patient, and the patient knew him. They had a strong relationship. He made the best judgment he could make.”

The VA Inspector General's Office is reviewing the case.

The agency's analysis of veteran suicides showed that despite whatever criticisms there were about VA care, veterans seeking mental treatment from the department have a lower suicide risk than those who do not. The VA reported that its crisis line, 800-273-8255 and press 1, has saved tens of thousands of lives.

The most difficult period for any veteran, according to those who study the problem, is making the transition from a war zone to a peaceful homefront — a change Ketchum ultimately could not navigate.

“He struggled with finding himself in the civilian world and having purpose," Nichols said. "They have this important job, and they come back here, and they don’t feel like any job is ever going to be as important as that.”

Corrections & clarifications: An earlier version of this story listed the incorrect phone number for the VA suicide crisis line.