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INTRODUCTION

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. The all-volunteer military has experienced multiple redeployments to the war zone, increased use of the reserve components of the military and National Guard, increased numbers of deployed women and parents of young children, and increases in the number of military personnel surviving severe injuries that in previous wars would have resulted in death (see Chapter 2 for a detailed discussion of the demographics of those deployed to OEF and OIF).


Although many men and women who return from a war zone successfully adjust to their lives out of theater, others have difficulty in readjusting or transitioning to family life, to their jobs, and to living in their communities after deployment. Some of the challenges are transitioning in and out of the civilian workforce, readjusting to partners who have assumed new roles during the separation period, readjusting to children who have matured and may resent additional oversight, re-establishing bonds with spouses and children, and managing the long-term health problems that are prevalent after deployment, such as posttraumatic stress disorder (PTSD), depression, and the sequelae of traumatic brain injury (TBI) (American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families, and Servicemembers, 2007; Slone et al., 2009).


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 PTSD, anxiety disorders, and depression—might hinder readjustment. In addition, TBI, often called the signature wound of OEF and OIF, is associated with a host of long-term adverse health outcomes, including unprovoked seizures, decline in neurocognitive function, dementia, and adverse social function outcomes, such as unemployment and diminished social relationships, depression, and aggressive behaviors (IOM, 2009).



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1 INTRODUCTION 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. The all-volunteer military has experienced multiple redeployments to the war zone, increased use of the reserve components of the military and National Guard, increased numbers of deployed women and parents of young children, and increases in the number of military personnel surviving severe injuries that in previous wars would have resulted in death (see Chapter 2 for a detailed discussion of the demographics of those deployed to OEF and OIF). Although many men and women who return from a war zone successfully adjust to their lives out of theater, others have difficulty in readjusting or transitioning to family life, to their jobs, and to living in their communities after deployment. Some of the challenges are transitioning in and out of the civilian workforce, readjusting to partners who have assumed new roles during the separation period, readjusting to children who have matured and may resent additional oversight, re-establishing bonds with spouses and children, and managing the long- term health problems that are prevalent after deployment, such as posttraumatic stress disorder (PTSD), depression, and the sequelae of traumatic brain injury (TBI) (American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families, and Servicemembers, 2007; Slone et al., 2009). 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 PTSD, anxiety disorders, and depression—might hinder readjustment. In addition, TBI, often called the signature wound of OEF and OIF, is associated with a host of long-term adverse health outcomes, including unprovoked seizures, decline in neurocognitive function, dementia, and adverse social function outcomes, such as unemployment and diminished social relationships, depression, and aggressive behaviors (IOM, 2009). 13

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14 RETURNING HOME FROM IRAQ AND AFGHANISTAN BACKGROUND 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 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 and mental health and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF and their families as a result of such deployment. The study was assigned to the Institute of Medicine (IOM). The study consists of two phases. Phase 1 is a preliminary assessment to identify findings on the physical and mental health and other readjustment needs of and on gaps in care for the members, former members, and families described in the legislation and to provide a roadmap for the second phase of the study. Phase 2 is to determine, in detail, the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed in OEF or OIF and the needs of their families and affected communities as a result of deployment (see Appendix A for the complete legislation). This report fulfills the requirement for phase 1 in the legislation. STATEMENT OF TASK The statement of task for this study evolved out of discussions between 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 of members and former members of the armed forces who were deployed in OEF or OIF and their families. The committee would also determine the goals of the second phase of the study, which is meant to provide a comprehensive assessment of the physical, mental, social, and economic effects of deployment and to identify gaps in care for members and former members of the armed forces who were deployed in OIF or OEF, their families, and affected communities. COMMITTEE’S APPROACH TO ITS CHARGE IOM appointed a committee of 16 experts to carry out the study. The committee members have expertise in sociology, psychiatry, rehabilitation, neurology, economics, epidemiology, survey research, and health policy and management. At its first meeting, the committee decided that its approach to gathering information would include considering data from the peer- reviewed literature; gathering data directly from DOD and VA; reviewing government articles, reports, and testimony presented to Congress; reviewing recent IOM reports on PTSD, TBI, and physiologic, psychologic, and psychosocial effects of deployment-related stress; and seeking input from the affected groups and communities. Those data gathering efforts were conducted for the committee to get a broad overview of possible readjustment needs as they relate to the long- lasting impact of deployments to OEF and OIF. The committee conducted extensive searches of the peer-reviewed literature in its attempts to understand readjustment needs and considered about 1,000 articles that resulted from

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INTRODUCTION 15 the 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 published information about the current wars, so the articles reviewed, although instructive about the numerous outcomes and long-term effects of deployment and redeployment, were a substitute for the information that the committee would like to have had. The committee also requested data from DOD and VA. Once the appropriate people in DOD were identified, the data requests were processed quickly. However, the data provided by VA have been incomplete; the committee’s deliberations in phase 2 will be facilitated by access to more complete information from the VA. The committee examined the basic demographic data that DOD and VA provided on the active-duty forces, the reserve components of the military, and the National Guard, such as the number of troops deployed and redeployed, the length of dwell time, marital status, the numbers of women deployed, the types of injuries reported, and health-care use by OEF and OIF veterans. DOD data were provided by the Defense Manpower Data Center and the Armed Forces Health Surveillance Center. Committee members also reviewed numerous reports that contained information on DOD and VA programs developed for those who have served in OEF and OIF and the costs of such programs; reports from the Government Accountability Office, the Congressional Budget Office, the inspectors general of VA and DOD, and the Congressional Research Service and congressional testimony relevant to its task; and several IOM reports on PTSD diagnosis (IOM, 2006), PTSD treatment (IOM, 2008b), the effects of deployment-related stress (IOM, 2008a), and the long-term outcomes related to TBI (IOM, 2009). Members of the committee understood that to carry out its task it would be important to talk to people who had firsthand knowledge of readjustment needs—active-duty personnel, veterans, family members, health-care providers, and community leaders. Thus, in addition to its literature reviews and six committee meetings, the committee held five town hall meetings. The committee used several 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 that have large military bases and troops who were deployed to Iraq and Afghanistan. In this first phase, the committee conducted the meetings in an effort to gain qualitative data; in phase 2, it expects to collect quantitative data from such meetings. The committee held 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 met with the Marine and Family Services Division 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 in 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 from 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 and veteran service organizations. The main issues discussed at those meetings are highlighted in Appendix B.

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16 RETURNING HOME FROM IRAQ AND AFGHANISTAN As a result of the committee’s extensive 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. ORGANIZATION OF THE REPORT Chapter 2 presents the demographics of the OEF and OIF populations and provides an overview of the extent of the problem with regard to adverse outcomes. Inasmuch as there was incomplete information on the needs of military personnel returning from OEF and OIF and their family members, the committee believed it prudent to examine the needs of veterans who returned from other wars, particularly the Vietnam War, which are described in Chapter 3. Chapter 4 details the findings regarding adverse physical, mental, and social outcomes, the effects of deployment, issues specific to women and minorities, and planning for the long-term needs. Chapter 5 provides a summary of the current federal response to the needs of OEF and OIF active-duty military, veterans, and family members. Chapter 6 contains the committee’s findings and recommendations and discusses how it plans to accomplish its phase 2 tasks as described by the legislation. The report has two appendixes: Appendix A is a copy of the legislation directing the committee’s work, and Appendix B summarizes some of the issues raised at its meetings around the country. REFERENCES American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families, and Servicemembers. 2007. The Psychological Needs of US Military Service Members and Their Families: A Preliminary Report. American Psychological Association. http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf (accessed July 20, 2009). IOM (Institute of Medicine). 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. IOM. 2008a. Gulf War and Health: Volume 6. Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC: The National Academies Press. IOM. 2008b. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. IOM. 2009. Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury. Washington, DC: The National Academies Press. Slone, L. B., A. S. Pomerantz, and M. J. Friedman. 2009. Vermont: A case history for supporting National Guard troops and their families. Psychiatric Annals 39(2):89-95.