The United States began combat operations in Afghanistan on October 7, 2001, in response to the September 11, 2001, terrorist attacks. That war is officially referred to as Operation Enduring Freedom (OEF), and the war in Iraq, which began in March 2003, is referred to as Operation Iraqi Freedom (OIF). Since October 2001, about 1.9 million US troops have been deployed to Afghanistan and Iraq. OEF and OIF have many unique features with regard to the military force being sent to fight those wars. The all-volunteer military has experienced multiple redeployments to the war zone, great use of the reserve components of the military and National Guard, deployment of high numbers of women and of parents of young children, and a high number of military personnel who survive severe injuries that in previous wars would have resulted in death.
Many men and women return from the war zone successfully and adjust to their lives out of theater, but others have had difficulty in readjusting or transitioning to family life, to their jobs, and to living in their communities after deployment. Numerous reports and articles in the popular press have drawn attention to those readjustment issues and have suggested that onset or exacerbation of mental disorders—particularly posttraumatic stress disorder (PTSD), anxiety disorders, and depression—might hinder readjustment. In addition, traumatic brain injury (TBI), often called the signature wound of OEF and OIF, is associated with a host of long-term adverse health outcomes, such as unprovoked seizures, decline in neurocognitive function, dementia, and adverse social-function outcomes, including unemployment and diminished social relationships, depression, and aggressive behaviors.
In response to the growing needs of OEF and OIF active-duty service members, veterans, and families, Congress passed Section 1661 of the National Defense Authorization Act for FY 2008. That section required that the secretary of defense, in consultation with the secretary of veterans affairs, enter into an agreement with the National Academies for a study of the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed to OIF or OEF and their families as a result of such deployment. The study was assigned to the Institute of Medicine (IOM) and is to be conducted in two phases. This report is a response to the congressional legislation for phase 1 of the study.
The statement of task for this study evolved out of discussions among the Department of Defense (DOD), the Department of Veterans Affairs (VA), and IOM. Specifically, it was determined that in phase 1, the IOM committee would identify preliminary findings regarding the physical and mental health and other readjustment needs for members and former members of the armed forces who were deployed to OEF or OIF and their families as a result of such deployment.
The committee would also determine how it would approach phase 2 of the study, which is meant to be a comprehensive assessment of the physical, mental, social, and economic effects and to identify gaps in care for members and former members of the armed forces who were deployed to OIF or OEF, their families, and their communities.
COMMITTEE’S APPROACH TO ITS CHARGE
IOM appointed a committee of 16 experts to carry out this study. The committee members have expertise in sociology, psychiatry, rehabilitation, neurology, economics, epidemiology, survey research, and health policy and management. The Committee on Readjustment Needs of Military Personnel, Veterans, and Their Families decided, at its first meeting, that its approach to gathering information would include consideration of data in the peer-reviewed literature; gathering of data directly from DOD and VA; review of government articles, reports, and testimony presented before Congress; and review of recent IOM reports on PTSD, TBI, and physiologic, psychologic, and psychosocial effects of deployment-related stress. The committee would also seek input from the affected groups and communities.
The committee conducted extensive searches of the peer-reviewed literature in its attempts to understand readjustment needs, and it considered about 1,000 articles that were identified through those searches. Many of the articles, however, focused on outcomes primarily of service in the Vietnam War rather than OEF and OIF. There was a paucity of information in the literature about the current wars; thus, the articles reviewed, although instructive about the numerous outcomes and long-term effects of deployment and redeployment, were in effect a substitute for the information that the committee would like to have had. The committee also requested data from DOD and VA.
The committee examined the basic demographic data on the active-duty forces, the reserve components of the military, and the National Guard that DOD and VA provided, such as number of troops deployed and redeployed, dwell time, marital status, numbers of women deployed, types of injuries reported, and health-care use by OEF and OIF veterans. DOD data were provided by the Defense Manpower Center and the Armed Forces Health Surveillance Center. Committee members reviewed numerous reports that informed it about DOD and VA programs developed for those who have served in OEF and OIF and the costs of such programs. They reviewed reports from the Government Accountability Office, the Congressional Budget Office, and the Congressional Research Service; inspector general reports for VA and DOD; and congressional testimony relevant to the committee’s task. And they reviewed several IOM reports on PTSD diagnosis, PTSD treatment, the effects of deployment-related stress, and longterm outcomes related to TBI.
Members of the committee understood that to carry out their task it would be important to talk to people who had first-hand knowledge of readjustment needs—active-duty personnel, veterans, family members, health-care providers, and community leaders. Therefore, in addition to its six meetings and literature reviews, the committee held several town hall meetings. The committee tried different venues and approaches for meeting with active-duty military personnel, veterans, and family members; some of the approaches were more successful than others.
Ultimately, the committee met with active-duty personnel, National Guard members, family members, veterans, and community leaders in cities, towns, and rural areas where there are large military bases and that were home to troops deployed to Iraq and Afghanistan. The committee held those meetings in Killeen, Texas (near Fort Hood); in Austin, Texas (at Camp Mabry); in Jacksonville and Fayetteville, North Carolina (near Camp Lejeune and Fort Bragg, respectively); and in Oceanside, California (near Camp Pendleton). Several committee members also met with the Marine and Family Services Division of Marine Corps Community Services at Camp Pendleton to gain a better understanding of the needs of marines and their family members and to become aware of the services offered. Those meetings were invaluable in providing the committee with an understanding of the challenges faced, not only by active-duty military with regard to accessing services but by providers who were trying to meet all the needs of service members and their families. Groups of committee members and staff went to Toledo, Ohio, to meet with National Guard members and representatives of the Ohio, Michigan, and Indiana Guard and to Watertown, New York, to meet with community leaders who serve those stationed at Fort Drum. The information-gathering sessions were open to the public. The committee also solicited comments from military-service and veteran-service organizations.
As a result of its approach to gathering information and its meetings and discussions, the committee decided to focus its findings on readjustment needs and gaps related to the conditions most frequently diagnosed in returning OEF and OIF active-duty personnel and veterans, such as PTSD and other mental health conditions, TBI, and social outcomes.
FINDINGS AND RECOMMENDATIONS
The committee is aware that it is addressing a dynamic set of issues in that the conflicts in Iraq and Afghanistan are going on now and issues and needs will continue to change. The committee also recognizes that VA, DOD, and other government agencies are actively responding to changing needs of active-duty service members, veterans, and their family members, and that many of the committee’s recommendations consequently might already be in the process of being addressed. Overall, the committee has found
• Relevant data on previous conflicts that are useful in addressing issues in the OEF and OIF populations.
• A relative paucity of data on OEF and OIF populations that are adequate to support evidence-based policy on most issues of concern.
• Information on a multitude of programs that have been developed to address the needs of the OEF and OIF populations.
• A scarcity of systematic or independent evaluation of such programs.
As the committee notes in Chapter 3, every war is unique in important respects. Empirical evidence collected from multiple wars documents that exposure to combat, other war-zone
stressors, or even deployment itself can have immediate and long-term physical, psychologic, and other adverse consequences. Some of the consequences have been generally constant throughout the history of warfare, even though the context and nature of warfare have changed dramatically. However, throughout history, society and culture have played a powerful role in how the effects of war on soldiers have been viewed, in the perceived nature and causes of the effects, and in how soldiers were treated for them. Although the experiences of those deployed to Iraq or Afghanistan bear similarities to the experiences of those deployed in previous conflicts, there are a number of distinctive and important differences in who is serving, how they are deployed, and how the conflicts are being fought. The differences have important consequences for the types and severity of challenges and readjustment problems likely to be experienced by the men and women serving in OEF and OIF and for the types of support that they and their families need both in theater and on their return home. Most of the differences are notable in that our armed forces and our country as a whole have not had relevant experience with the key features of organization and warfare that make these conflicts most distinctive. Furthermore, the research that has been conducted shares a set of limitations with studies of the experiences in prior conflicts. Those limitations include
• Reliance on samples of convenience, which limits their external validity (generalizability).
• Reliance on brief screening instruments to identify key outcomes and to estimate prevalence, which limits internal validity.
• Use of cross-sectional designs, which limits the ability to support causal inference and to elucidate the course of disorders.
• Assessment of narrow sets of risk and protective factors, which results in under-specified models with a high risk of bias.
• Conduct of many studies by VA or DOD, rather than by independent third parties, which raises important questions about the accuracy of respondents’ self-reports, particularly with regard to sensitive issues.
All those limitations are understandable given the fiscal and practical challenges involved in conducting long-term outcome studies (for example, longitudinal epidemiologic studies are expensive and difficult to implement). To be useful in the formulation of policy, however, studies need to be both scientifically sound and comprehensive. The committee is aware of the Millennium Cohort Study, several studies being conducted by RAND, and other studies that are in progress. Additional studies that address some of the methodologic challenges identified above—for instance, using probability sampling, diagnostic interviewing, and longitudinal designs—will be needed to move the field forward.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on readjustment needs of returning OEF and OIF veterans, their families, and their communities that explicitly addresses methodologic and substantive gaps in completed and ongoing research. For example, the support of large-scale, independent studies with longitudinal designs, probability sampling, comprehensive clinical assessment of key outcomes, and more fully specified models that include objective biologic measures should be considered.
In Chapter 4, the committee presents many of its preliminary findings and notes that research and program development are needed to substantiate the potential efficacy and cost
effectiveness of developing protocols for the long-term management of TBI and polytrauma. The array of potential health outcomes associated with TBI suggests that injured service members will have long-term psychosocial and medical needs from both persistent deficits and problems that develop in later life. Access to rehabilitation therapies—including psychologic, social, and vocational—is required initially with the onset of deficits and will persist over time as personal and environmental factors change leading to loss of functional abilities.
VA has put into place a comprehensive system of rehabilitation services for polytrauma, including TBI (see Chapter 5), that addresses acute and chronic needs that arise in the initial months and years after injury. However, protocols to manage the lifetime effects of TBI are not in place and have not been studied for either military or civilian populations. As in other chronic health conditions, long-term management for TBI may be effective in reducing mortality, morbidity, and associated costs.
The committee recommends that the Department of Veterans Affairs conduct research to determine the potential efficacy and cost effectiveness of developing protocols for the long-term management of service members who have polytrauma and traumatic brain injury. The approaches considered should include
• Prospective clinical surveillance to allow early detection and intervention for health complications.
• Protocols for preventive interventions that target high-incidence or highrisk complications.
• Protocols for training in self-management aimed at improving health and well-being.
• Access to medical care to treat complications.
• Access to rehabilitation services to optimize functional abilities.
Another issue of concern, discussed in Chapter 4, is the critical shortage of health-care professionals—especially those specializing in mental health—to meet the demands of those returning from theater in Iraq and Afghanistan and their family members. Psychologists, psychiatrists, social workers, and other mental health professionals who do serve the military and veteran communities have large caseloads, especially in some locations that result in underserving of patients, high rates of burnout, and turnover. The committee heard of those problems repeatedly in its town hall meetings both from mental health professionals and from those who were waiting for appointments for treatment. Many of the people who spoke at the committee’s meetings, from Fort Hood to Camp Pendleton, emphasized that those who are in need of mental health treatment have to wait too long for initial appointments or between appointments.
The committee recommends that the Department of Defense and the Department of Veterans Affairs quantify the number and distribution of mental health professionals needed to provide treatment to the full population of returning service members, veterans, and their families who suffer from mental health disorders, such as PTSD, major depression, and substance abuse, so that they can
readjust to life outside of theater. The committee also recommends that the Department of Defense and the Department of Veterans Affairs continue to implement programs for the recruitment and retention of mental health professionals, particularly to serve those in hard-to-reach areas.
Stigma, real or imagined, is perceived by military personnel who are (or are considering) seeking care for mental health or substance-abuse problems. And active-duty military and veterans fear that visits to a mental health provider will jeopardize their careers because of the military’s long-standing and understandable policy of reporting mental health and substanceabuse problems to the chain of command. Such a policy is a disincentive to seeking care, underestimates the extent of the problem or the disease burden, and may ultimately compromise readiness.
The committee recommends that the Department of Defense actively promote an environment to reduce stigma and encourage treatment for mental health and substance-use disorders in an effort to improve military readiness and ability to serve. The committee also recommends that the Department of Defense undertake a systematic review of its policies regarding mental health and substance-abuse treatment with regard to issues of confidentiality and the relation between treatment-seeking and military advancement.
As noted in Chapter 4, the demands of the current conflicts have made compliance with DOD’s rotational policies (for example, length of deployments and length of time between deployments) difficult. The implications and potential consequences of shorter dwell time and more frequent deployments are of obvious importance for understanding the readjustment needs of service members and their families; policies that help to ease reintegration are paramount. Little research has been conducted to evaluate whether service members who undergo thirdlocation decompression (that is, for service members to have time with their comrades and peers in a restful situation and prepare themselves for going back to their families and communities) have better outcomes than those who do not, but anecdotal reports from foreign troops have been favorable. For example, Canadian forces have returned home from Afghanistan via Guam or Cyprus by spending 5 days of structured time with their units, which allows some time for decompression; they are also required to work about three half-days at their home base, and this provides additional time to adjust to life back in Canada and to ease the transition back into family life.
The committee recommends that the Department of Defense formally assess whether a “third-location decompression” program would be beneficial for US combat troops. Third-location decompression has the potential to allow troops to have time to begin to readjust before returning home and to family responsibilities.
Primarily on the basis of studies of previous conflicts, Chapter 4 highlights many issues related to families, spouses, children, women, and racial and ethnic minority-group members. It also discusses preliminary findings related to social issues related to deployment, such as employment, education, income, debt, wages, and earnings, also on the basis of data on previous wars. The committee found that active-duty service members, reservists, and veterans face
hardships resulting from service in Iraq and Afghanistan that extend beyond physical and mental health problems. They also face numerous readjustment needs that affect their ability to adjust to life outside theater. Those needs, in turn, create hardships for their families.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on the social and economic effects of deployment and multiple deployments on families. For example, research should examine the effects of multiple deployments on domestic violence and maltreatment of children, as well as on financial well-being.
Women now constitute 14% of deployed forces in the US military, and, although technically they are barred from serving in combat, a growing and unprecedented number of female soldiers are deployed to combat areas where their lives are at risk. Although all service members are exposed to high levels of workplace stress, women in the military face some unique stressors, such as sexual harassment and trauma exposure that may affect their mental health and emotional well-being. Female veterans report a higher burden of medical illness, worse quality-of-life outcomes, and earlier psychologic morbidity than do men who are exposed to the same levels of trauma. Both the military and family life require commitment and loyalty, and servicewomen who have families may experience intense conflict between the demands of their military roles and their family roles. Some of the specific issues for women are military-related sexual harassment and assault and the resulting mental health problems, histories of premilitary trauma, specific health-care needs, pregnancy and the postpartum period, and the configuration of family roles (such as mother, spouse, and caregiver of aging parents).
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund studies to evaluate the effectiveness of mental health treatments currently being provided to women and to identify potential new treatments designed specifically to address women’s unique circumstances and stressors, such as sexual harassment and assault, PTSD, and premilitary trauma.
Although the military has a tradition of being one of the most desegregated institutions in US society, there is evidence that minority-group members have greater health and mental health needs than their white counterparts. For example, some minority groups may be at greater risk for PTSD and other adverse outcomes than nonminority groups exposed to comparable traumatic events. In addition, minority groups are less likely than nonminority groups to use mental health services and quicker to drop out of treatment. Therefore, health-care needs and other needs of minorities might be different from those of whites and are not yet well understood. All those issues raise a number of research questions that should be addressed.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on culturally sensitive treatment approaches targeted toward minorities. Research is also needed on utilization patterns of currently available services by minority populations and the efficacy of such services to improve health outcomes.
The burden borne by wounded warriors and their families, and thus the public responsibility to treat or compensate them, will persist for many years. Historically, the peak demand for compensation has lagged behind the end of hostilities by 30 years or more, so the maximum stress on support systems for OEF and OIF veterans and their families might not be felt until 2040 or later. To produce timely, accurate, and transparent forecasts of veterans’ needs and demands on the system, it will be important to put into place mechanisms for anticipating the needs of veterans and their families so that the needs can begin to be addressed. Although long-term costs are less predictable and potentially are the subject of much controversy, because the costs are certain to be substantial and will be acutely felt by veterans and their families, highquality cost forecasts are needed so that resources can be allocated better.
The committee recommends that Congress appropriate funds and direct the Department of Veterans Affairs to expand the role of its actuary to produce annual long-term forecasts of costs associated with all health and disability benefits that are consistent with the practices of Social Security and Medicare.
As the committee notes in Chapter 5, numerous programs exist or have been developed to meet the readjustment needs of OEF and OIF service members, veterans, and their families. There appears to be little coordination between programs and a lack of communication about the programs to those who need the services (there are notable exceptions, such as Military OneSource), especially those living in remote areas. Furthermore, the efficacy of the programs is unknown inasmuch as most programs have not been evaluated and there is no clear chain of accountability. No specific organization is providing stewardship of the available programs to assist those in need.
The committee recommends that the Department of Defense and the Department of Veterans Affairs oversee coordination and communication of the multitude of programs that have been created in response to the needs of Operation Enduring Freedom and Operation Iraqi Freedom service members, veterans, and their family members in an effort to maximize their reach and effectiveness. The committee also recommends that there be independent evaluation of these programs with standardized evaluation designs and assessment of outcomes.
As previously noted, the legislation (see Appendix A) that mandated this study directed that it be conducted in two phases. The specific aims of the second phase are to carry out a comprehensive assessment of the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed to OEF or OIF and their families as a result of such deployment and to assess the psychologic, social, and economic effects of such deployment on members, former members, and their families, including
• Effects of multiple deployments to OEF and OIF on members, former members, and their families.
• The scope of the neurologic, psychiatric, and psychologic effects of TBI on members and former members of the armed forces and their family members, including the efficacy of
current approaches to treatment for TBI in the United States and the efficacy of approaches to screening and treatment for TBI in DOD and VA.
• Effects of undiagnosed injuries, such as PTSD and TBI, an estimate of the long-term costs associated with such injuries, and the efficacy of approaches to screening and treatment for PTSD and other mental health conditions in DOD and VA.
• Sex-specific and ethnic-group–specific needs and concerns of members of the armed forces and veterans.
• Particular needs and concerns of children of members of the armed forces, taking into account different age groups, effects on development and education, and the mental and emotional well-being of children.
• An assessment of the particular educational and vocational needs of members and former members and their families and the efficacy of existing educational and vocational programs to address such needs.
• Effects of deployments associated with OEF and OIF on communities that have high populations of military families, including military housing communities and townships that are home to deployed members of the National Guard and reserves, and an assessment of the efficacy of programs that address community outreach and education concerning military deployments of community residents.
• Effects of increases in numbers of older and married members of the armed forces on readjustment requirements.
• The development, based on such assessments, of recommendations for programs, treatments, or policy remedies targeted at preventing, minimizing, or addressing the identified effects, gaps, and needs.
• The development, based on such assessments, of recommendations for additional research on identified needs.
The committee has given considerable thought to a framework to advance its task. The remainder of this chapter will describe the committee’s approach to the formidable task given to it by Congress.
Inasmuch as the situations in Afghanistan and Iraq continue to evolve—as do the needs of OEF and OIF active-duty service members, veterans, family members, and communities—the committee suggests a flexible approach that can respond to the dynamic circumstances. The committee will expand its ranks by adding experts to assist in data collection and analysis, and it expects to have the input of its new members in the final approach for phase 2 before making its plan final. Phase 2 will probably involve collecting both qualitative and quantitative data. Possible approaches to address the statement of task that will be considered by the committee are described below.
1. Review of funded research and gap analysis
In phase 2, the committee expects to conduct a comprehensive assessment of newly completed and current research on OEF and OIF populations to determine what additional research is needed to identify and assess the magnitude of readjustment needs. The committee will perform a gap analysis based on the concerns outlined in the legislation (see Appendix A) and the funded research; the committee members will recommend topics for additional studies and provide the details for the approach to the research. The committee will require the
cooperation of DOD and VA to compile a comprehensive list of newly completed and currently funded research.
2. Systematic reviews of interventions
The committee will conduct systematic literature reviews on interventions to address readjustment problems for social services and physical and mental health services and will recommend evidence-based interventions. There is a need to define optimal standards of care to restore and maintain health for OEF and OIF active-duty service members and veterans. The committee will review the literature on treatment modalities for TBI and PTSD and make recommendations for the best treatment approaches and for culturally sensitive treatments.
3. Identify access-to-care issues
The committee intends to examine issues related to access to care, specifically the extent to which DOD and VA treatment facilities are in areas where the need is greatest. The committee will gather data on demographics and on the number and types of services and programs that are available on the installations and in the surrounding communities (such as local hospitals, social services, and VA medical centers) to map actual resource allocation. The committee will also gather data on the numbers and types of health and mental health diagnoses being made by DOD and VA and examine the numbers of health and mental health professionals in an effort to determine workforce needs. The committee will need the cooperation of DOD and VA as it attempts to gather information to complete this task. DOD has already been helpful in providing detailed demographic information to the committee.
4. Generate opportunities for research to fill identified knowledge gaps
Informed by knowledge gaps identified in paragraphs 1 and 2 above, the committee plans to develop a request for proposals for a large-scale independent study or a suite of studies that would aim to improve understanding of the scope of the consequences of OEF and OIF and that would offer solutions to remediate those needs. Such a study should not duplicate current efforts but rather should be complementary and reflect the state of the science. In general, we anticipate that the study should have longitudinal designs inasmuch as not all consequences of deployment are immediately obvious (or even immediately measurable). It should use probability sampling so that all who served have a nonzero probability of being in the sample (that is, sampling cannot be complete until the war ends, or the sample would be drawn from all those who had served as of a specified date). That will be critical for external validity (generalizability) and to capture the varying nature of exposure by time and place of service. In addition, incorporation of clinical assessment, moving beyond screening instruments, will be required. We expect that some research started in phase 2 might not be completed by the time phase 2 concludes. However, our intention is that this work will lay a comprehensive base for future implementation science that deals directly with the readjustment needs of OEF and OIF active-duty service members, veterans, their families, and their communities. We also note that the committee will lay the foundation for qualitative research if a need for it becomes apparent in the reviews being discussed in paragraphs 1 and 2 above.
Implicit in much of what the committee has found and has written is that dealing with the population-level consequences of OEF and OIF will require policy changes. The scope of potential policy remedies will be targeted at preventing, minimizing, or addressing the impacts, gaps, and needs identified during the committee’s work. It is anticipated that this work will generate specific recommendations that may require statutory changes to implement.