By James Dao / The New York Times

The act of killing is as fundamental to war as oxygen is to fire. Yet it is also the one thing many combat veterans avoid discussing when they return home, whether out of shame, guilt or a deep fear of being misunderstood.

But a new study of Iraq war veterans by researchers in San Francisco suggests that more discussion of killing may help veterans cope with an array of mental health problems stemming from war.

The study, published last week in The Journal of Traumatic Stress, found that soldiers who reported having killed in combat, or who gave orders that led to killing, were more likely to report the symptoms of post-traumatic stress disorder, alcohol abuse, anger and relationship problems. The study was based on data from health assessments conducted on about 2,800 soldiers who returned from Iraq in 2005 and 2006.

Shira Maguen, a psychologist at the San Francisco Veterans Affairs Medical Center and the principal investigator on the study, said the results suggested that mental health professionals need to incorporate killing more explicitly into their assessments and treatment plans for veterans. That would include finding ways to discuss the impact of killing, in public forums and in private treatment, to reduce the stigma and shame, she argued.

“We need as a culture to find ways to not blame soldiers who are ashamed of killing,” said Ms. Maguen, who is also an assistant professor of psychiatry at the University of California, San Francisco. She said the study was the first to look into the links between killing and the mental health problems of Iraq veterans.

The researchers found that 40 percent of the soldiers surveyed reported killing or being responsible for killing during deployment. Twenty-two percent reported symptoms of stress disorder, 32 percent reported symptoms of depression and 25 percent met criteria for alcohol abuse.

Mental health experts said the new study confirmed findings from research on Vietnam veterans and did not break much new ground. But they said it underscored that treating stress disorder among veterans is often very different from treating it in people who, say, have been raped or have been in car accidents.

“People don’t understand the moral ambiguity of combat and why it is so hard to get over it,” said Rachel Yehuda, a professor of psychiatry at Mount Sinai School of Medicine in New York. “What makes combat veterans ill is not always about being a victim, but, in some instances, feeling very much both a perpetrator and a victim at the same time.”

Barbara Van Dahlen, the president of Give an Hour, a nonprofit organization that provides free mental health services to returning troops, said getting veterans to open up about killing can be an immensely time-consuming challenge, particularly if it involved noncombatants. “Even though they work through that it wasn’t their fault, those things are much more difficult to get over than having killed an enemy soldier,” Ms. Van Dahlen said.

Some experts said military law had also complicated therapy by having unclear rules about when a soldier’s conversations with a therapist are protected from legal action. The mere threat that those conversations could be used in war crimes prosecutions discourages many troops and veterans from seeking counseling, those experts say.

Shannon Meehan, a retired Army captain who has written about the crippling guilt he felt about calling in an artillery strike that killed an Iraqi family by accident, said it took him months to tell his therapist about the deaths. “This is common,” Mr. Meehan said. “A good deal never come forward and share it with their therapists.”

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