6
FINDINGS, RECOMMENDATIONS, AND PHASE 2

The legislation for this study directed that it be conducted in two phases (see Appendix A). Specifically, Congress directed the National Academies to conduct 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 Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and their families as a result of such deployment. This report covers the first phase of the study called for in the legislation.


To inform its work during the initial phase of the study, the committee surveyed the literature and met with active-duty and reserve military personnel, veterans, family members, military and veteran service organizations, and representatives of the Department of Defense (DOD) and the Department of Veterans Affairs (VA). 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. This chapter summarizes the committee’s findings, offers its recommendations, and suggests a framework for approaching the second phase of its study.

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-



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6 FINDINGS, RECOMMENDATIONS, AND PHASE 2 The legislation for this study directed that it be conducted in two phases (see Appendix A). Specifically, Congress directed the National Academies to conduct 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 Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and their families as a result of such deployment. This report covers the first phase of the study called for in the legislation. To inform its work during the initial phase of the study, the committee surveyed the literature and met with active-duty and reserve military personnel, veterans, family members, military and veteran service organizations, and representatives of the Department of Defense (DOD) and the Department of Veterans Affairs (VA). 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. This chapter summarizes the committee’s findings, offers its recommendations, and suggests a framework for approaching the second phase of its study. 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- 155

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156 RETURNING HOME FROM IRAQ AND AFGHANISTAN 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. These differences include dependence on an all-voluntary military; service members who are somewhat older and who are more likely to be married with children; greater representation of women and minorities in the military; and greater reliance on the National Guard and reserves. Finally, there have been more frequent deployments, longer deployments, and shorter dwell time than in previous wars. 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 makes 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 underspecified 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

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FINDINGS, RECOMMENDATIONS, AND PHASE 2 157 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 high- risk 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.

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158 RETURNING HOME FROM IRAQ AND AFGHANISTAN 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 substance- abuse 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 third- location 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.

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FINDINGS, RECOMMENDATIONS, AND PHASE 2 159 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 addressed. 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

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160 RETURNING HOME FROM IRAQ AND AFGHANISTAN 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 high- quality 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 Operation Enduring Freedom and Operation Iraqi Freedom 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, especially those living in remote areas (there are notable exceptions, such as Military OneSource). 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. PHASE 2 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

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FINDINGS, RECOMMENDATIONS, AND PHASE 2 161 • 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

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162 RETURNING HOME FROM IRAQ AND AFGHANISTAN 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, as well as, potential strategies aimed at reducing readjustment needs. 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 the text above.

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FINDINGS, RECOMMENDATIONS, AND PHASE 2 163 5. Identify policy remedies 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.

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