Returning Home from Iraq and Afghanistan Assessment of Readjustment Needs of Veterans, Service Members, and Their Families (2013) / Chapter Skim
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BACKGROUND In response to the return of large numbers of veterans from Iraq and Afghanistan with physical-health and mental-health problems and to the growing readjustment needs of activeduty service members, veterans, and their family members, Congress included Section 1661 of the National Defense Authorization Act for fiscal year 2008. That section required the secretary of defense, in consultation with the secretary of veterans affairs, to enter into an agreement with the National Academies for a study of the physical-health, mental-health, and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF, their families, and their communities as a result of such deployment.
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The committee approached its task by identifying and reviewing data in the peer-reviewed literature; reviewing government reports and testimony before Congress; reviewing recent IOM reports on posttraumatic stress disorder (PTSD) , traumatic brain injury (TBI)
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RECOMMENDATIONS To inform its work during the second phase of its study, the committee read the literature, collected data and attempted data analyses, oversaw ethnographic research, and tabulated current research in the OEF and OIF populations. The committee's recommendations are presented below.
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DOD and VA use different thresholds for some of the same mental-health screening and assessment instruments, such as the Primary-Care PTSD screen and the PTSD Checklist for PTSD and the Patient Health Questionnaire for depression. Parts of VA and DOD clinical guidance lack recommendations for a specific assessment instrument and leave the selection of instrument to the clinician, for example, for suicide-risk assessments and TBI neurocognitive assessments.
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VA is implementing a robust clinician-training program to disseminate evidence-based psychotherapies, but the program appears to lack periodic clinician assessments beyond the 6-month training period to ensure that continued treatment fidelity is maintained. Current approaches for training clinicians on the management of comorbid conditions (by disseminating clinician resources, for example)
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The committee found that little information is available on the potential effectiveness of broad-based, universal prevention efforts aimed at military children and their families. In addition, most treatment interventions for family members have been developed and tested in civilian communities and lack evidence of their effectiveness for military families.
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The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other relevant federal agencies fund research on the effects of Operation Enduring Freedom and Operation Iraqi Freedom deployments on communities. Such research should include current indicators of community well being, such as measures of economic performance, availability of social and support services, law-enforcement activity, and school and educational functioning.
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Evaluation of the effectiveness of transition-assistance programs, with research that examines employment patterns after separation from the military over time, will provide data to ensure that scarce resources can be allocated to effective programs. Further study might focus on whether employment tax credits are a cost-effective means of expanding employment for Operation Enduring Freedom and Operation Iraqi Freedom veterans and whether programs to counsel and prepare service members for long-term postservice careers are effectively implemented.
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The committee recommends improved coordination of care and services between the Department of Defense and the Department of Veterans Affairs medical treatment facilities, including the completion of an interoperable or single combined electronic health record for all care that begins with entry into military service and continues throughout care in the Department of Veterans Affairs system after transition. Stigma is still a problem for military personnel in care or seeking care for mental-health or substance-abuse problems.
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The two departments should examine issues related to women's circumstances and stressors -- such as military workplace stress, sexual harassment and assault, posttraumatic stress disorder, and premilitary trauma -- in an effort to reduce disparities and to provide health care that is sensitive to their needs and preferences. PROPOSED DATA ANALYSES There has been little quantitative characterization of the issues described in the legislation, but the committee identified a wide array of data and databases available in DOD, VA, and other federal agencies that could be used to address many of the questions posed by the legislation that motivated its work.
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Comprehensive data analyses will require establishment of systematic, timely processes for using available government data and linking them in such a way as to improve the characterization of issues of interest. No databases or files fully integrate basic deployment and demographic data with data on health outcomes, treatment or transition-of-care files, data on access to care, records of employment before and after deployment, and data on other processes and outcomes.
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The committee believes that such coordination will greatly enhance the ability of researchers and the government to link data held by multiple agencies to allow the types of analyses recommended above.
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