4
PRELIMINARY FINDINGS

This chapter highlights findings related to the health consequences of service in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and readjustment needs resulting from deployment; it also examines the social consequences of deployment and the special issues faced by women and ethnic minorities; finally, it examines the need to plan for the long-term support of veterans, families, and communities affected by deployment to OEF and OIF. Inasmuch as this is the preliminary or initial phase of the committee’s report, the topics discussed in this chapter are not addressed in detail. Rather, the committee is raising and exploring issues and expects to examine all the topics of concern in more detail in phase 2. Data on OEF and OIF veterans are lacking, but the committee members have examined information from studies of Vietnam veterans if they believed them to be instructive with regard to OEF and OIF veterans. The paucity of data is not surprising as studies take time to design, sample strategies need to be approved, data need to be analyzed, and the wars are ongoing. It took at least 15 years after the Vietnam War before the National Vietnam Veterans Readjustment Study began.

CONSEQUENCES OF SERVICE IN OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM FOR MILITARY PERSONNEL AND THEIR FAMILIES AND EFFECTS ON READJUSTMENT

Since the beginning of the wars in Afghanistan (OEF) and Iraq (OIF), there have been 5,286 fatalities among US military service members.1 During the same period, 36,021 have been wounded in Iraq and Afghanistan as a direct result of hostile actions; the Army has borne the brunt of the casualties (CRS, 2009). Blasts from improvised explosive devices (IEDs) have caused most of the deaths and nonfatal injuries. Injuries from blast exposure due to IEDs have resulted in numerous physical and mental health outcomes, such as traumatic brain injury (TBI), amputation, spinal-cord injury, chronic pain, headache, injury to the eye and ear, posttraumatic stress disorder (PTSD), and major depression. Military personnel exposed to multiple blasts have an increased probability of sustaining an injury that can lead to severe or long-term physical and psychologic impairments (Nelson et al., 2008). Various impairments often occur together, making treatment and readjustment more difficult. In recognition of the additional challenges faced by veterans suffering comorbid deployment-related conditions, the Department of Veterans

1

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4 PRELIMINARY FINDINGS This chapter highlights findings related to the health consequences of service in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and readjustment needs resulting from deployment; it also examines the social consequences of deployment and the special issues faced by women and ethnic minorities; finally, it examines the need to plan for the long-term support of veterans, families, and communities affected by deployment to OEF and OIF. Inasmuch as this is the preliminary or initial phase of the committee’s report, the topics discussed in this chapter are not addressed in detail. Rather, the committee is raising and exploring issues and expects to examine all the topics of concern in more detail in phase 2. Data on OEF and OIF veterans are lacking, but the committee members have examined information from studies of Vietnam veterans if they believed them to be instructive with regard to OEF and OIF veterans. The paucity of data is not surprising as studies take time to design, sample strategies need to be approved, data need to be analyzed, and the wars are ongoing. It took at least 15 years after the Vietnam War before the National Vietnam Veterans Readjustment Study began. CONSEQUENCES OF SERVICE IN OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM FOR MILITARY PERSONNEL AND THEIR FAMILIES AND EFFECTS ON READJUSTMENT Since the beginning of the wars in Afghanistan (OEF) and Iraq (OIF), there have been 5,286 fatalities among US military service members. 1 During the same period, 36,021 have been wounded in Iraq and Afghanistan as a direct result of hostile actions; the Army has borne the brunt of the casualties (CRS, 2009). Blasts from improvised explosive devices (IEDs) have caused most of the deaths and nonfatal injuries. Injuries from blast exposure due to IEDs have resulted in numerous physical and mental health outcomes, such as traumatic brain injury (TBI), amputation, spinal-cord injury, chronic pain, headache, injury to the eye and ear, posttraumatic stress disorder (PTSD), and major depression. Military personnel exposed to multiple blasts have an increased probability of sustaining an injury that can lead to severe or long-term physical and psychologic impairments (Nelson et al., 2008). Various impairments often occur together, making treatment and readjustment more difficult. In recognition of the additional challenges faced by veterans suffering comorbid deployment-related conditions, the Department of Veterans 1 Statistics are through November 24, 2009. 61

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62 RETURNING HOME FROM IRAQ AND AFGHANISTAN Affairs (VA) in 2005 defined polytrauma as “injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability” (VA, 2005). Since then, its definition has been expanded to include concurrent injury to two or more body parts or systems that results in cognitive, physical, psychologic, or other psychosocial impairments (VA, 2009b). Many military personnel returning from OEF and OIF appear to have more complex and emotional trauma than has been seen in past wars (Friedemann-Sanchez et al., 2008). That observation may be due, in part, to an improved chance of survival because of the widespread use of body armor, improved battlefield medical response, and advances in aeromedical evacuation. Polytrauma patients in particular have complex rehabilitation needs, including addressing and treating for pain, TBI, PTSD, and other comorbid conditions to facilitate readjustment (Sayer et al., 2009). Although TBI, amputations, PTSD, and major depression are distinct postcombat health outcomes, they cause overlapping long-term, possibly lifelong, effects on people’s lives. People affected by those types of combat-related injuries and mental health disorders tend to report poorer health and impaired function in many life activities than people who do not suffer those types of injuries. Moreover, physical injuries and mental health disorders often require treatment by multiple health-care services for an extended period. The problem of polytrauma and the associated lifelong, recurring comorbid conditions, such as PTSD and chronic pain, requires the development of integrated approaches to clinical care that can replace traditional treatment systems that focus on isolated problems (Belanger et al., 2005; Gironda et al., 2009). Those injuries also have the potential to affect family life even if the injured service members recover fully. For example, family members may need to relocate if the proper treatment facilities are not available close to home (Cozza et al., 2005). Injuries that result in long-term changes in behavior or abilities can seriously challenge marriages, thrusting the spouse into a caregiving role, increasing the risk of depression and other psychologic problems, and increasing the likelihood of divorce (Blais and Boisvert, 2005; Calhoun et al., 2002). The committee has decided, in this preliminary report, to focus on the most serious health, psychologic, and social outcomes related to OEF and OIF service. Those outcomes and possible readjustment needs associated with them are discussed below. Traumatic Brain Injury and Related Blast Injuries Throughout OEF and OIF, explosive devices have become more powerful, their detonation systems more creative, and their additives more devastating. TBI 2 is the most common injury among those wounded in OEF and OIF and is a significant cause of mortality and morbidity. In 2003–2007, the Military Health System (MHS) recorded that 43,779 patients had a diagnosis of TBI (CRS, 2009). The estimates vary: some studies have found that about 10– 20% of veterans returning from OEF and OIF have TBI (Elder and Cristian, 2009; Tanielian and Jaycox, 2008), and others have found that TBI accounts for up to one-third of all battlefield injuries (Meyer et al., 2008). Although penetrating brain injuries are easily identified, closed TBI is more common and, when mild, can go unnoticed. A concern for troops, veterans, and their 2 Brain injuries may be categorized as mild, moderate, or severe (see Silver et al., 2005); the Defense and Veterans Brain Injury Center in collaboration with the Armed Forces Health Surveillance Center publishes the annual incidence of brain injury by severity and by branch of military (DOD, 2009).

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PRELIMINARY FINDINGS 63 family members is that substantial long-term effects have been associated with TBI (IOM, 2009). In some cases a TBI can go undetected until the service member returns home and can no longer function as he or she did before deployment; this can result in frustration and problems for both service member and family alike (Zeitzer and Brooks, 2008). A recent Institute of Medicine (IOM) report (2009) noted that numerous adverse long-term outcomes are related to TBI. Although some acute outcomes, such as some neurocognitive and psychosocial dysfunction, resolve or lessen over time, other sequelae, such as psychiatric outcomes, become more apparent several years after injury. Many studies have found a dose–response relationship with regard to TBI severity and outcome: generally, the more severe the TBI, the more severe the outcome. However, the IOM report identified several outcomes that can persist even after mild TBI, including unprovoked seizures, depression, aggression, and postconcussive symptoms, such as memory problems, dizziness, and irritability. TBI can cause life-long impairments, and rehabilitation and recovery might take many years. One common complication of TBI is pain (Nampiaparampil, 2008), particularly headache, and there is growing evidence that it can be a long-term problem (Gironda et al., 2009). A study of OEF and OIF veterans diagnosed with TBI found that those with neurocognitive impairments were more likely to have headache, migraine-like headache, more severe pain, and more frequent headache than veterans without neurocognitive impairment (Ruff et al., 2008). Similarly, a recent study (Theeler and Erickson, 2009) found an association between a history of mild head trauma, usually caused by blast exposure, and onset or worsening of headache in combat troops; it was also noted that the soldiers diagnosed with TBI usually experienced migraine-type headaches. There is clear evidence of increased mortality in the acute phase after moderate to severe TBI and for some time following in both military and civilian populations (Baguley et al., 2000; Brown et al., 2004; Corkin et al., 1984; Harrison-Felix et al., 2004; Lewin et al., 1979; Ratcliff et al., 2005; Rish et al., 1983; Selassie et al., 2005; Shavelle and Strauss, 2000; Walker et al., 1971; Weiss et al., 1982). In the military literature, posttraumatic epilepsy in patients who initially survive penetrating head injury is associated with an increased risk of death and about a 5-year decrease in life expectancy (Corkin et al., 1984; Walker et al., 1971; Weiss et al., 1982). Studies of the subset of more severely injured patients who survive initial hospitalization and require inpatient rehabilitation have shown a worse prognosis that is consistent with the greater degree of residual compromise: mortality some 2–7 times as high as that in age- and sex-matched comparison populations (Brown et al., 2004; Harrison-Felix et al., 2004; Ratcliff et al., 2005; Selassie et al., 2005). TBI can also lead to disruptions in higher-level functions of everyday life, including social relationships, independent living, and employment. Numerous studies have documented that penetrating brain injuries have adverse consequences for long-term employment outcomes (Dikmen et al., 1994; Doctor et al., 2005; McLeod et al., 2004; Schwab et al., 1993). Moreover, although some impairments might be related to injuries to other parts of the body sustained at the time of TBI, moderate to severe TBI leads to more functional impairment than do injuries to other parts of the body alone (Dikmen et al., 1995; Gerberich et al., 1997; McLeod et al., 2004; Oddy et al., 1978; Ommaya, 1996). The adverse effects of TBI on leisure and recreation, social relationships, functional status, quality of life, and independent living clearly affect readjustment and family life and relationships. By one year after injury, psychosocial problems appear to be greater than problems in basic activities of daily living (IOM, 2009).

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64 RETURNING HOME FROM IRAQ AND AFGHANISTAN Most long-term outcomes of TBI were observed at or soon after the time of injury and persisted, presumably indefinitely. However, other outcomes were observed to develop later, possibly as a result of an interaction with aging processes. Conditions found, in at least some studies, to emerge or re-emerge in later life included cognitive deficits (e.g., Corkin et al., 1989), depression (e.g., Holsinger et al., 2002), suicide (e.g., Teasdale and Engberg, 2001), premature death (e.g., Harrison-Felix et al., 2004), progressive dementia (e.g., Plassman et al., 2000), and parkinsonism (e.g., Bower et al., 2003). Posttraumatic Stress Disorder and Traumatic Brain Injury PTSD (discussed in more detail below) can co-occur with TBI (Hill et al., 2009; IOM, 2008b). It has been noted that physical trauma and psychologic trauma reported by OEF and OIF service members and veterans rarely appear in isolation and often present with more than one medical condition simultaneously (that is, they are comorbid) (Lew et al., 2009). Although the data on rates of comorbidity in the OEF and OIF population are sparse, research in civilians suggests that those with co-occurring mental and physical problems typically require more specialized treatment and have poorer outcomes than those with a single condition only (Shalev et al., 1998). A recent RAND report (Tanielian and Jaycox, 2008) estimated that some combination of comorbid PTSD, major depression, and TBI is not uncommon in OEF and OIF veterans. The report noted that about one-third of service members who have been deployed have at least one of the three conditions, and about 5% manifest symptoms of all three (Tanielian and Jaycox, 2008). Furthermore, of 289,328 OEF and OIF veterans seen at VA health care facilities following deployment, 106,726 (36.9%) received mental health diagnoses and of those receiving any such diagnosis, 29% had two and 33% had 3 or more different mental health conditions (Seal et al., 2009). Of those veterans, 62,929 (21.8%) were diagnosed with PTSD and 50,432 (17.4%) with depression. Hoge and Castro (2006) found that the prevalence of PTSD in soldiers who had physical injuries was 31.8%. In a more recent study of over 2,000 postdeployment active-duty service members, those who reported loss of consciousness had the highest rate of PTSD, 43.9%; the rate of PTSD was 27.3% in those who had altered mental status but no loss of consciousness, 16.2% in those who had only physical injuries, and 9.1% in those who reported no injury (Hoge et al., 2008). Moreover, mild TBI accompanied by symptoms of PTSD and other mental problems (Schneiderman et al., 2008) was more common in blast-injured patients than in those who had non-blast-related injuries. In a study of National Guard troops returning from the Gulf War, most of the PTSD reported at 2 years was present at 6 months after deployment, but symptom severity increased over the interval. Those who were highly symptomatic at 6 months were still highly symptomatic 2 years later (Southwick et al., 1995). Auditory and Visual Impairment Tympanic membrane perforation is a blast injury that occurs in about 10% of those wounded by combat-related explosions (Ritenour et al., 2008). In many cases, hearing loss accompanies TBI. Lew et al. (2007a) reported on the prevalence and characteristics of auditory dysfunction in patients admitted to a VA TBI inpatient unit before and after the start of OEF. Their findings indicated a high prevalence of hearing loss and tinnitus in a growing population of returning service members. Inasmuch as effective communication is needed for successful

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PRELIMINARY FINDINGS 65 rehabilitation, especially in patients who have comorbid TBI, clinically significant hearing loss presents problems for readjustment. In addition to chronic pain, headaches, and hearing loss, ocular trauma is a direct consequence of blast injury and TBI. Combat troops who are exposed to a blast that results in mild TBI are at risk for visual dysfunction, and combat troops who have polytrauma are at risk for visual dysfunction and impairment (Brahm et al., 2009). It has been noted that TBI occurs in 67% of cases of combat ocular trauma, and that ocular trauma is a common finding in TBI cases (Weichel et al., 2009). Those outcomes, in addition to numerous long-term outcomes associated with TBI (discussed above), indicate that planning is needed for addressing injured service members’ long-term psychologic, psychosocial, and medical needs. Polytrauma As noted earlier, OEF and OIF active-duty military personnel are experiencing higher survival rates than in previous wars. The overall survival rate among wounded troops is about 90%; increased survival rates are attributed to the widespread use of body armor and improved battlefield procedures and medical evacuation (CBO, 2007b). However, the protection offered by body armor has probably resulted in more veterans surviving injuries that in past conflicts would have led to polytrauma and death, but which now result in immediate or later amputations. As reported by the Army Office of the Surgeon General, from September 2001 to January 12, 2009, there were 1,184 amputations in personnel deployed to OIF and OEF, nearly three-quarters of which were major amputations (CRS, 2009). IEDs caused 55% of the 1,184 OIF and OEF amputations. Of the 1,184 amputations, 77% were in the Army, 19% in the Marines, 2% in the Air Force, and 2% in the Navy (CRS, 2009). OIF and OEF amputees typically receive care at Landstuhl Regional Medical Center in Germany and are then sent to Walter Reed Army Medical Center, where they may stay for several months. Amputees often experience acute and chronic pain, including phantom limb and residual limb or stump pain (Ketz, 2008). They may also face long-term psychologic problems (Ebrahimzadeh and Rajabi, 2007). Ebrahimzadeh and Hariri (2009) reported that 54% of amputees having persistent functional, social, and psychiatric problems, yet only 26% of patients were receiving psychologic treatment. Another common problem reported by returning service members that co-occurs with other injuries is chronic pain (Clark et al., 2007; Gironda et al., 2006; Lew et al., 2007b), itself a leading cause of disability in the civilian population (Stewart et al., 2003). In a study of 100 OEF and OIF veterans, about 47% reported at least mild pain, and 28% reported moderate to severe pain; among the 67 veterans with chronic pain conditions, 82% had a documented diagnosis of musculoskeletal or connective tissue disorders (Gironda et al., 2006). Moreover, pain is known to be associated with a high prevalence of mental health disorders, including PTSD (Otis et al., 2009). A more recent study of 429 OEF and OIF veterans (Helmer et al., 2009) found that more severe chronic pain, PTSD, and depression adversely affected veterans’ ability to perform daily activities and so made readjustment for the veterans and their family members more difficult. In a recent review, pain from polytrauma was found to pose numerous challenges during and after rehabilitation treatment (Dobscha et al., 2009). Patients who present with both pain and mental health disorders may have more functional impairment than those with single conditions. Studies of patients treated for both pain and the mental health disorder do not consistently show improvement when the mental health disorder is treated alone; this suggests that both conditions

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66 RETURNING HOME FROM IRAQ AND AFGHANISTAN need to be addressed (Otis et al., 2009). Assessment and intervention efforts are further complicated when the injuries include TBI. Factors associated with worse outcomes include multiplicity of injuries, head injury or cognitive disability, and lower-limb injuries. 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. Mental Health Disorders High rates of service-related mental health disorders among military personnel and veterans who have deployed to OEF and OIF have been reported (Erbes et al., 2007; Hoge et al., 2004, 2006; Kolkow et al., 2007; Office of the Surgeon Multinational Force–Iraq and Office of the Surgeon General United States Army Medical Command, 2006a, 2006b, 2008; Seal et al., 2007; Sundin et al., 2010; Tanielian and Jaycox, 2008; US Army Surgeon General, 2003, 2005), and the prevalence of those disorders will grow as the conflicts continue. Frequently diagnosed psychiatric disorders include mood disorders, such as depression, and anxiety disorders, such as PTSD, panic disorder, and generalized anxiety disorder. An increased risk of substance-use disorders (alcohol and drug abuse and dependence) and suicides often co-occurs with those mental disorders. This section describes the disorders, their reported prevalence in the OEF and

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PRELIMINARY FINDINGS 67 OIF military and veteran populations, and the readjustment challenges faced by people who have these disorders. Major Depression Major depression is the most common mood disorder reported in civilian populations; it is characterized by persistent feelings of sadness accompanied by several symptoms related to changes in appetite or sleeping patterns, loss of interest in activities, fatigue, inability to concentrate, and hopelessness or suicidal thoughts. A 2008 RAND report (Tanielian and Jaycox, 2008) reviewed 12 studies that assessed the prevalence of depression in active-duty service members who served in OEF and OIF. None of the studies used a diagnostic instrument to diagnose depression, and findings were based on self-report symptom measures only. However, on the basis of the prevalence estimates, major depression in active-duty service members ranged from 5% (Hoge et al., 2006; Kolkow et al., 2007; US Army Surgeon General, 2005) to 37% (Lapierre et al., 2007). Depression is associated with a decrease in quality of life. The World Health Organization projects that it will be the second-most common contributor to disability worldwide in 2020; it is already the second-most common contributor to disability in people 15–44 years old in both sexes combined (WHO, 2010). In the general population, about 80% of persons who had depression reported some difficulty in daily functioning because of their symptoms (Pratt and Brody, 2008). In more severe cases, persons who had a lifetime history of major depression were 10 times as likely to report having thought about killing themselves (OR 9.6, 95% CI 7.5- 12.3), 11 times as likely to have made a nonfatal suicide attempt (OR 11.0, 95% CI 7.1-20.3) (Kessler et al., 1999), and almost 4 times as likely to meet alcohol-dependence criteria (OR 3.7, 95% CI 3.1-4.4) (Grant et al., 2004). In military populations, those who had depression were less likely to be employed than those who did not (Savoca and Rosenheck, 2000). Vietnam veterans who had depression also had 45% lower hourly wages than veterans who did not (Savoca and Rosenheck, 2000). Similarly, Vietnam veterans who had depression tended to report more marital and family conflict, including domestic violence, than those who did not. In a survey of 11,870 white men randomly sampled from Army bases between 1989 and 1992, presence of depressive symptoms was positively associated with the presence and severity of domestic violence (Pan et al., 1994). The investigators found that for each 20% increase in depressive symptoms, there was a 74% increase in the likelihood of husband-to-wife aggression. Posttraumatic Stress Disorder PTSD is a commonly diagnosed mental health disorder in OEF and OIF service members. It can develop after the direct, personal experience or witnessing of an event that poses a perceived threat of death or serious injury. The risk of developing PTSD is also higher among those who have suffered pre-service trauma, such as childhood sexual abuse or physical abuse (Tolin and Foa, 2006). Symptoms that characterize PTSD arise in the aftermath of a traumatic exposure and include re-experiencing of the traumatic event through flashbacks and nightmares; avoidance of people, places, and situations associated with the trauma; and hyperarousal (difficulty in sleeping and in concentrating and exaggerated startle) (IOM, 2006). The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), which is considered the gold standard for psychiatric diagnoses in the United States, recognizes that the onset of PTSD may be acute, beginning within 6 months of exposure to the traumatic event, or delayed, beginning 6

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68 RETURNING HOME FROM IRAQ AND AFGHANISTAN months or more after the traumatic event. Symptoms typically begin shortly after exposure— even on the first day (North et al., 1999). PTSD can be diagnosed only if symptoms persist for at least a month; similar symptoms that last less than a month are diagnosable as acute stress disorder. The latency period between exposure and development of symptoms that meet the diagnostic criteria is variable; it may be years before the symptoms become fully manifest (Bremner et al., 1996; Bryant and Harvey, 2002; Carty et al., 2006; Gray et al., 2004; Green et al., 1990; Op Den Velde et al., 1996; Port et al., 2001; Ruzich et al., 2005). Moreover, PTSD is considered to be chronic by DSM-IV-TR (DSM-IV Text Revision) criteria if symptoms persist for 3 months or longer. PTSD also can be chronic with no remission, or it can be recurrent with periods of remission and recurrence (Friedman, 2003). In US troops deployed to Afghanistan and Iraq, symptoms of PTSD are most commonly reported after deployment. Service members who experience combat exposure and those who are wounded are at higher risk for PTSD. The Department of Defense (DOD) conducted a mental health survey of Army soldiers and marines deployed to Iraq in 2003, 2004, and 2006. In 2003, 16% of the soldiers and marines met the screening criteria (not necessarily DSM diagnosis) for PTSD while deployed; in 2004, 14% met the screening criteria; and in 2006, 17% of soldiers and 14% of marines met the screening criteria (Office of the Surgeon Multinational Force–Iraq and Office of the Surgeon General United States Army Medical Command, 2006b). Moreover, the risk of PTSD symptoms 3–4 months after deployment was 6.2% in Army troops returning from Afghanistan and 12.9% in Army soldiers and 12.2% in marines returning from Iraq (Hoge et al., 2004). Since September 2001, the MHS has recorded positive screening results for PTSD in 39,365 service members. According to CRS (2009), the MHS has spent $63.8 million on care and $13.1 million on prescription drugs for treating those with PTSD symptoms. In a RAND study of OEF and OIF veterans, 18.5% reported depression or PTSD (Tanielian and Jaycox, 2008), slightly higher than the prevalence found in its review of 22 other studies, which showed that 5–15% of veterans experienced PTSD symptoms when deployed to war zones. The study also suggested that prevalence of PTSD symptoms increases with time after deployment (the readjustment period) (Tanielian and Jaycox, 2008). Studies of US service members deployed to war zones have used self-report screening instruments rather than structured diagnostic interviews conducted by mental health professionals to diagnose mental health conditions. According to the RAND report (Tanielian and Jaycox, 2008), due to methodologic differences in outcome measurement, the extant studies may have underestimated the prevalence of PTSD and depression in their postdeployment samples. Most studies also used convenience samples, which may not be representative of the entire force deployed to war zones. In addition, inasmuch as OEF and OIF are ongoing, the risks may yet change. For example, service members deployed to Iraq earlier in the conflict were at higher risk for PTSD than those deployed to Afghanistan, but recent changes in military focus in the two theaters might reverse that pattern. PTSD can interfere with functioning and quality of life. There is considerable evidence that symptoms of combat-related trauma and posttraumatic stress are inversely associated with service members’ relationship quality and stability. For example, 30 years after their military service, 10% of the Vietnam veterans in a community sample reported they still had severe PTSD symptoms, and those 10% reported less satisfaction with their marriages and sex lives and more difficulties with parenting. Veterans with more severe PTSD symptoms were more likely to have been divorced, and veterans who had reported severe symptoms 15 years earlier had

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PRELIMINARY FINDINGS 69 become even less satisfied with their marriages and lives (Koenen et al., 2008). Cook et al. (2004) found similar relationship disruptions 50 years after World War II in a sample of US prisoners of war. In marriage, emotional numbing has been associated with loss of intimacy (Cook et al., 2004; Galovski and Lyons, 2004; Solomon et al., 2008). The PSTD arousal symptom cluster3 seems to promote veterans’ expressions of anger (Beckham et al., 2000) and violence toward their partners (Marshall et al., 2005; Solomon et al., 2008). There is evidence that PTSD disrupts functioning in relationships with children. Fathers who have PTSD have been characterized as withdrawn, irritable, and controlling (Dekel and Goldblatt, 2008; Galovski and Lyons, 2004). In a study of 66 male Vietnam veterans who had combat-related PTSD, emotional numbing was more strongly related than other symptoms to aspects of the parent–child relationship, including positive sharing, contact, and overall quality (Ruscio et al., 2002). A recent study focused on 199 military veterans who served in Iraq or Afghanistan after 2001 and who were referred to military behavioral health clinicians from primary care (Sayers et al., 2009). Veterans who had depression or PTSD were five times as likely to report problems with family readjustment as those who did not, including feeling like guests in their own homes and reporting that their children acted afraid or without warmth toward them. Almost one-third of the veterans reported that their partners were afraid of them. In a study of PTSD in civilians, Breslau (2001) found that when symptoms were most severe, about 25% of both men and women in a population of young adults felt that they were unable to work during the entire 30-day period during which they experienced the symptoms. When inability to work was added to reports of reduced activity, almost 39% of the 20 men and 44% of the 44 women reported that they were unable to do their jobs or had to reduce their activities. When young people who had a diagnosis of PTSD, other psychiatric diagnoses, or no psychiatric diagnosis were compared, those who had PTSD were twice as likely to limit their activities as those who were diagnosed with other psychiatric disorders and four times as likely as those who had no diagnosis. Adding to the mental health readjustment challenges of OEF and OIF service members and veterans is the shortage of mental health–care professionals being reported by the military and mass media. The committee’s own preliminary review found that the mental health services available to OEF and OIF service members and veterans are poorly distributed. For example, a shortage of mental health–care professionals, at least in some geographic areas (especially less- populated areas), has been reported. Feedback from health-care providers in the field showed concerns that at some army installations and VA hospitals, the mental health–care personnel are overwhelmed by the number of soldiers and veterans who seek treatment. Anecdotal evidence suggests that in some locations service members and veterans have long wait times or must travel long distances to see mental health providers. In connection with the heavier case loads, there have been reports that facilities in remote areas are finding it difficult to recruit and retain highly qualified providers. The committee heard from providers—especially at the town hall meeting held in Killeen, Texas, near Fort Hood— who stated that it is difficult to retain mental health clinicians because they can be better 3 The arousal symptom cluster includes the symptoms listed under part D of the PTSD criteria (309.81) in DSM-IV: sleeping difficulty, irritability and angry outbursts, difficulty concentrating, hypervigilence, and exaggerated startle response.

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70 RETURNING HOME FROM IRAQ AND AFGHANISTAN compensated in private practice (see Appendix B). They also noted that it is difficult to recruit qualified clinicians to remote areas because the clinicians have other opportunities to work and live in more attractive communities. Suicide Suicidal behavior is one of the most serious consequences of mental disorders. It is the 11th-most common cause of death in the United States (NIMH, 2009). In the Western world, women attempt suicide three times as frequently as men, but men are four times as likely to die from suicide as women because of the methods used (for example, men use firearms) (CDC, 2009). A number of studies have assessed the association between combat exposure and suicide; the results have been inconsistent. In a study of Vietnam veterans, an increased risk of attempting suicide was observed during the early followup period (CDC, 1987), but the increase in risk did not persist in a 30-year followup of the cohort (Boehmer et al., 2004). In another study, veterans who had PTSD continued to have an increased risk of committing suicide 30 years after service (Boscarino, 2006); this suggests that those who have PTSD may be particularly vulnerable. In a prospective followup study of over 320,000 men, veterans were twice as likely to die of suicide as nonveterans in the general population (Kaplan et al., 2007). Because of the high rates of mental disorders in service members returning from Afghanistan and Iraq, there are concerns about elevated rates of suicide. According to DOD, the rate of suicide in the military in 2003 was comparable with the rate across all ages of the general US population (about 10 per 100,000) (Allen et al., 2005). Since then, the Army has reported a record of over 140 suicides in active-duty soldiers in 2008; in November 2009, the Army released data suggesting that suicides in 2009 could exceed that number. In January–October 2009, there were 133 reported suicides (90 confirmed and 43 pending); in the same period in 2008, there were 115 confirmed suicides in active-duty soldiers (Department of the Army, 2009). Those figures do not take into account the other branches of the US military, and it is not possible to determine whether the rate of suicide in all military personnel has increased. However, some data suggest that there are especially vulnerable groups, notably veterans who served in the active component and veterans who have mental disorders (Kang and Bullman, 2008). More people fail at suicide attempts than are successful. Those who fail at suicide attempts often injure themselves seriously and require medical care. The total lifetime cost of self-inflicted injuries among the general US population in 2000 was about $33 billion, of which $1 billion was for medical care and $32 billion for lost productivity (Corso et al., 2007). In addition, those who attempt suicide often suffer from depression and other mental disorders and are at increased risk for attempting it again. Little research has been conducted to examine the consequences of suicide on family members. That lack of data is not limited to the consequences of suicide on the family and social networks, but also extends to the military unit. Those left behind have been found to be at risk for complicated grief reactions, mental disorders, and even suicide. A study by Farberow et al. (1992) found that spouses bereaved because of deaths from natural causes appeared less distressed 6 months after their spouse’s death than those whose spouses died of suicide. The study reported higher levels of grief and depression after the first year, and found that spouses

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PRELIMINARY FINDINGS 71 bereaved because of deaths from natural causes reported receiving more emotional support than those whose spouses committed suicide. Many feel guilt and blame themselves for their perceived failure to prevent the suicide (Reynolds and Cimbolic, 1988). In addition, survivors are judged more severely by society than those who suffer other types of loss (Range, 1998; Stillion, 1996). The committee heard repeatedly that there is a critical shortage of health-care professionals—especially those specializing in mental health—to meet the demands of people returning from theater in Iraq and Afghanistan and their family members. The psychologists, psychiatrists, social workers, and other mental health professionals who do serve the military and veteran communities have large caseloads (especially in some locations), and this results in underserved patients and high rates of burnout and turnover. The committee is aware that DOD is taking steps to meet the mental health care needs of its service members, but more remains to be done. 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. Substance-Use Disorders DSM-IV defines substance-use disorders as dependence4 on or abuse5 of drugs or alcohol. The disorders are often comorbid with depression and PTSD. A recent IOM report determined that there is evidence of an association between deployment to a war zone and alcohol and drug abuse and dependence (IOM, 2008a); however, there are no data available on drug abuse in OEF and OIF active duty and veterans. That lack of data is not surprising, inasmuch as active-duty soldiers who abuse drugs are at risk for dishonorable discharge. Thus, many studies do not collect data on substance abuse. Initial surveys, however, have suggested that problems with substance abuse and dependence, particularly alcohol abuse and dependence, in OEF and OIF veterans are being reported when they return (Hoge et al., 2004; Jacobson et al., 2008; Lande et al., 2008; Stahre et al., 2009). A recent study found that 43% of active-duty service members reported binge drinking6 in the preceding month (Stahre et al., 2009). Another study of three Army units and one Marine Corps unit found that deployment to Iraq or Afghanistan was associated with higher prevalence of alcohol misuse compared to predeployment prevalence (Hoge et al., 2004). In a study of reserve and National Guard personnel, those who were deployed to Iraq or Afghanistan and reported combat exposure were 4 Dependence is characterized by tolerance, withdrawal, need for increasing amounts, persistent desire, and unsuccessful efforts to reduce use of a substance. 5 Abuse is characterized by recurrent use of a substance to the point where it causes domestic, occupational, interpersonal, or legal problems or use in physically hazardous situations. 6 The study defined binge drinking as consuming more than four drinks for men and more than three drinks for women during a single event.

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106 RETURNING HOME FROM IRAQ AND AFGHANISTAN Hoge, C. W., D. McGurk, J. Thomas, A. L. Cox, C. C. Engel, and C. A. Castro. 2008. Mild traumatic brain injury in US soldiers returning from Iraq. New England Journal of Medicine 358(5):453-463. Hoge, C. W., A. Terhakopian, C. A. Castro, S. C. Messer, and C. C. Engel. 2007. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq War veterans. American Journal of Psychiatry 164(1):150-153. Holbrook, T. L., D. B. Hoyt, M. B. Stein, and W. J. Sieber. 2002. Gender differences in long- term posttraumatic stress disorder outcomes after major trauma: Women are at higher risk of adverse outcomes than men. Journal of Trauma 53(5):882-888. Holsinger, T., D. C. Steffens, C. Phillips, M. J. Helms, R. J. Havlik, J. C. S. Breitner, J. M. Guralnik, and B. L. Plassman. 2002. Head injury in early adulthood and the lifetime risk of depression. Archives of General Psychiatry 59(1):17-22. Hope, J. B., D. B. Christman, and P. C. Mackin. 2009. An Analysis of the Effect of Reserve Activation on Small Business. Annandale, VA: SAG Corporation. Hourani, L. L., and H. Yuan. 1999. The mental health status of women in the Navy and Marine Corps: Preliminary findings from the Perceptions of Wellness and Readiness Assessment. Military Medicine 164(3):174-181. Huebner, A. J., and J. A. Mancini. 2005. Adjustments Among Adolescents in Military Families When a Parent Is Deployed: Final Report to the Military Family Research Institute and Department of Defense Quality of Life Office. Alexandria, VA: National Military Family Association. Huebner, A. J., J. A. Mancini, R. M. Wilcox, S. R. Grass, and G. A. Grass. 2007. Parental deployment and youth in military families: Exploring uncertainty and ambiguous loss. Family Relations 56(2):112-122. Hughes, J. G., N. M. Earnshaw, N. Greenberg, R. Eldridge, N. T. Fear, C. French, M. P. Deahl, and S. Wessely. 2008. The use of psychological decompression in military operational environments. Military Medicine 173(6):534-538. IOM (Institute of Medicine). 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. IOM. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. 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. Jacobson, I. G., M. A. Ryan, T. J. Hooper, T. C. Smith, P. J. Amoroso, E. J. Boyko, G. D. Gackstetter, T. S. Wells, and N. S. Bell. 2008. Alcohol use and alcohol-related problems before and after military combat deployment. Journal of the American Medical Association 300(6):663-675.

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PRELIMINARY FINDINGS 107 Jensen, P. S., D. Martin, and H. Watanabe. 1996. Children’s response to parental separation during Operation Desert Storm. Journal of the American Academy of Child and Adolescent Psychiatry 35(4):433-441. Kang, H. K., and T. A. Bullman. 2008. Risk of suicide among US veterans after returning from the Iraq or Afghanistan war zones. Journal of American Medical Association 300(6):652- 653. Kang, H., N. Dalager, C. Mahan, and E. Ishii. 2005. The role of sexual assault on the risk of PTSD among Gulf War veterans. Annals of Epidemiology 15(3):191-195. Kang, H. K., B. H. Natelson, C. M. Mahan, K. Y. Lee, and F. M. Murphy. 2003. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: Population-based survey of 30,000 veterans. American Journal of Epidemiology 157:141- 148. Kaplan, M. S., N. Huguet, B. H. McFarland, and J. T. Newsom. 2007. Suicide among male veterans: A prospective population-based study. Journal of Epidemiology and Community Health 61(7):619-624. Karney, B. R., and J. S. Crown. 2007. Families Under Stress: An Assessment of Data, Theory, and Research on Marriage and Divorce in the Military. Santa Monica, CA: RAND Corporation. http://www.rand.org/pubs/monographs/MG599/ (accessed January 11, 2010). Kelley, M. L. 1994. The effects of military-induced separation on family factors and child behavior. American Journal of Orthopsychiatry 64(1):103-111. Kelley, M. L., E. Hock, J. F. Bonney, M. S. Jarvis, K. M. Smith, and M. A. Gaffney. 2001. Navy mothers experiencing and not experiencing deployment: Reasons for staying in or leaving the military. Military Psychology 13(1):55-71. Kessler, R. C., G. Borges, and E. E. Walters. 1999. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry 56(7):617-626. Kessler, R., W. Chiu, O. Demler, and E. Walters. 2005. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62:617-627. Ketz, A. K. 2008. Pain management in the traumatic amputee. Critical Care Nursing Clinics of North America 20(1):51-57. Kleykamp, M. 2009. A great place to start?: The effect of prior military service on hiring. Armed Forces and Society 35(2):266-285. Koenen, K. C., J. M. Stellman, S. D. Stellman, and J. F. Sommer Jr. 2003. Risk factors for course of posttraumatic stress disorder among Vietnam veterans: A 14-year follow-up of American Legionnaires. Journal of Consulting and Clinical Psychology 71(6):980-986. Koenen, K. C., S. D. Stellman, J. F. Sommer Jr., and J. M. Stellman. 2008. Persisting posttraumatic stress disorder symptoms and their relationship to functioning in Vietnam veterans: A 14-year follow-up. Journal of Traumatic Stress 21(1):49-57. Kolkow, T. T., J. L. Spira, J. S. Morse, and T. A. Grieger. 2007. Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Military Medicine 172(5):451-455.

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