Returning Home from Iraq and Afghanistan

Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families

Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families

Board on the Health of Select Populations

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Returning Home from Iraq and Afghanistan Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14763-7 International Standard Book Number-10: 0-309-14763-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. IOM (Institute of Medicine). 2010. Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org .

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COMMITTEE ON THE INITIAL ASSESSMENT OF READJUSTMENT NEEDS OF MILITARY PERSONNEL, VETERANS, AND THEIR FAMILIES GEORGE W. RUTHERFORD, MD, (chair) Salvatore Pablo Lucia Professor and Vice Chair, Department of Epidemiology and Biostatistics; Director, Prevention and Public Health Group, Global Health Sciences, University of California, San Francisco MARGARITA ALEGRÍA, PhD, Professor, Department of Psychiatry, Harvard Medical School; Director, Center for Multicultural Mental Health Research, Cambridge Health Alliance DAN G. BLAZER, MD, PhD, J.P. Gibbons Professor of Psychiatry, Duke University Medical Center IBOLJA CERNAK, MD, ME, PhD, Medical Director, Biomedicine Business Area, National Security Technology Department, Johns Hopkins University Applied Physics Laboratory JOHN D. CORRIGAN, PhD, Professor and Director, Division of Rehabilitation Psychology, Department of Physical Medicine and Rehabilitation, Ohio State University RYAN D. EDWARDS, PhD, Assistant Professor of Economics, Queens College and the Graduate Center, City University of New York; Faculty Research Fellow, National Bureau of Economic Research SANDRO GALEA, MD, DrPH, Gelman Professor and Chair, Department of Epidemiology, Columbia University Mailman School of Public Health JANICE L. KRUPNICK, PhD, Professor and Director, Trauma and Loss Program, Department of Psychiatry, Georgetown University RICHARD A. KULKA, PhD, Group Vice President, Survey Research, Abt Associates Inc. BENNETT L. LEVENTHAL, MD, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY; Department of Child and Adolescent Psychiatry, New York University, and New York University Child Study Center SHELLEY MACDERMID WADSWORTH, PhD, Professor of Family Studies; Director, Center for Families; Director, Military Family Research Institute; Department of Child Development and Family Studies, Purdue University ALAIR MACLEAN, PhD, Assistant Professor, Department of Sociology, Washington State University SAMUEL J. POTOLICCHIO, MD, Professor of Neurology, Department of Neurology, George Washington University Medical Center SCOTT L. RAUCH, MD, Chair, Partners Psychiatry and Mental Health; President and Psychiatrist in Chief, McLean Hospital; Professor of Psychiatry, Harvard Medical School WILLIAM E. SCHLENGER, PhD, Principal Scientist, Abt Associates Inc. ALBERT W. WU, MD, MPH, Professor, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Professor of Medicine, School of Medicine, Johns Hopkins University v

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STUDY STAFF CAROLYN FULCO, Scholar NAOKO ISHIBE, Senior Program Officer ROBERTA WEDGE, Senior Program Officer RENEE WLODARCZYK, Senior Program Associate PATRICK BAUR, Research Associate JOE GOODMAN, Senior Program Assistant NORMAN GROSSBLATT, Senior Editor CHRISTIE BELL, Financial Officer FREDRICK ERDTMANN, Director, Board on the Health of Select Populations vi

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REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: William R. Beardslee, Department of Psychiatry, Children’s Hospital of Boston Linda Bilmes, Harvard Kennedy School, Harvard University John Cawley, Department of Policy Analysis and Management, Cornell University Archie R. Clemins, Caribou Technologies, Inc. Colleen Conway-Welch, School of Nursing, Vanderbilt University Meredith Kleykamp, Department of Sociology, University of Kansas Kathryn Kotrla, Texas A&M Health Science Center in Round Rock John A. Parrish, Center for Integration of Medicine and Innovative Technology, Boston Penny F. Pierce, University of Michigan School of Nursing Peter Rosen, University of Arizona Tucson School of Medicine Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by James S. House, Institute for Social Research, University of Michigan. Appointed by the National Research Council and the Institute of Medicine, he was responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the author committee and the institution. vii

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CONTENTS PREFACE .................................................................................................................................... xiii ACRONYMS.................................................................................................................................xv SUMMARY.....................................................................................................................................1 Background .................................................................................................................................1 Statement of Task........................................................................................................................2 Committee’s Approach to its Charge..........................................................................................2 Findings and Recommendations .................................................................................................3 Phase 2 ........................................................................................................................................8 1 INTRODUCTION ....................................................................................................................13 Background ...............................................................................................................................14 Statement of Task......................................................................................................................14 Committee’s Approach to Its Charge........................................................................................14 Organization of the Report........................................................................................................16 References .................................................................................................................................16 2 OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM: DEMOGRAPHICS AND IMPACT .........................................................................................17 Demographics of the All-Volunteer Military............................................................................18 Operation Enduring Freedom and Operation Iraqi Freedom: Unique Characteristics .............25 Current Impact on Operation Enduring Freedom and Operation Iraqi Freedom Service Members...............................................................................................................................29 Overview of Health Outcomes ...............................................................................................29 Overview of Social Outcomes ................................................................................................30 Overview of Federal Readjustment Resources .........................................................................33 Conclusion ................................................................................................................................34 References .................................................................................................................................34 3 SUMMARY OF FINDINGS FROM PREVIOUS CONFLICTS.............................................39 From Ancient Greece and Rome to the Russo-Japanese War...................................................40 World War I, World War II, and the Korean Conflict ..............................................................41 The Vietnam War......................................................................................................................42 Assessment of Exposure to Combat and Other War-Zone Stressors .....................................43 Outcomes (Readjustment Problems) ......................................................................................44 Risk Factors for Readjustment Problems ...............................................................................48 The Persian Gulf War ...............................................................................................................49 Summary ...................................................................................................................................50 References .................................................................................................................................54 4 PRELIMINARY FINDINGS....................................................................................................61 Consequences of Service in Operation Enduring Freedom and Operation Iraqi Freedom for Military Personnel and Their Families and Effects on Readjustment..................................61 ix

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x CONTENTS Traumatic Brain Injury and Related Blast Injuries.................................................................62 Polytrauma..............................................................................................................................65 Mental Health Disorders.........................................................................................................66 Deployment ...............................................................................................................................73 Deployment and Military Families.........................................................................................74 Deployment and Military Spouses..........................................................................................76 Deployment and Children.......................................................................................................78 Deployment and Social Outcomes..........................................................................................80 Women and Minorities..............................................................................................................86 Women....................................................................................................................................86 Ethnicity, Race, and Culture...................................................................................................90 Projecting the Lifelong Burden of War.....................................................................................93 References .................................................................................................................................98 5 THE CURRENT RESPONSE ................................................................................................117 Overview of Federal Benefits Available to Service Members, Veterans, and Their Families117 The Department of Defense..................................................................................................117 The Department of Veterans Affairs ....................................................................................122 Overview of Programs and Services for Operation Enduring Freedom and Operation Iraqi Freedom Active-Duty Service Members, Veterans, and Their Families.........................128 Programs for Physical Needs................................................................................................128 Programs for Mental Health Needs ......................................................................................132 Programs to Meet the Social Needs of Service Members, Veterans, and Their Families ....138 Programs for National Guard and Reserve Members, Women, Minority-Group Members, and the Homeless .............................................................................................................146 Summary .................................................................................................................................149 References ...............................................................................................................................149 6 FINDINGS, RECOMMENDATIONS, AND PHASE 2 ........................................................155 Findings and Recommendations .............................................................................................155 Phase 2 ....................................................................................................................................160 APPENDIX A LEGISLATION ..............................................................................................165 National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181 110th Congress (2nd Session)....................................................................................................165 APPENDIX B TOWN HALL MEETINGS............................................................................169 Killeen, Texas (Fort Hood): Army .......................................................................................169 Austin, Texas (Camp Mabry): Texas National Guard..........................................................170 Toledo, Ohio: Michigan, Indiana, and Ohio National Guard ...............................................171 Fayetteville, North Carolina (Fort Bragg): Army.................................................................171 Jacksonville, North Carolina (Camp Lejeune): Marine Corps .............................................172 San Diego, California (Camp Pendleton): Marine Corps.....................................................172 Watertown, New York (Fort Drum): Army..........................................................................173 Tables, Figures, and Boxes TABLE 2.1 Service Members Deployed by Component as of April 30, 2009 .............................17

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CONTENTS xi TABLE 2.2 Percentage of Active-Component Members by Age and Service Branch in 2009....19 TABLE 2.3 Percentage of Active-Component Members by Age and Service Branch in 2009....20 TABLE 2.4 Active-Component Members with Children by Service Branch in 2007 ..................21 TABLE 2.5 Health-Care Priority Groups ......................................................................................33 TABLE 4.1 Racial and Ethnic Characteristics of Deployed Personnel to OEF and OIF from September 11, 2001, to the Present, First Deployment Only.................................................91 TABLE 5.1 Veterans Integrated Service Networks and Numbers of Facilities ..........................125 TABLE 5.2 Polytrauma System of Care......................................................................................131 FIGURE 2.1a Age of children (active component); FIGURE 2.1b Age of children (reserve component). ...........................................................................................................................22 FIGURE 2.2 Counties of residence of deployed OEF and OIF Army (active-component) military personnel. ...............................................................................................................................23 FIGURE 2.3 Counties of residence of deployed OEF and OIF Army National Guard military personnel. ...............................................................................................................................24 FIGURE 2.4 Counties of residence of deployed OEF and OIF Army reserve military personnel.25 FIGURE 2.5 a Number of times deployed to OEF or OIF by branch of military service (active component). ...........................................................................................................................27 FIGURE 2.6 Number of times deployed to OEF or OIF by branch of military service reserves).27 FIGURE 2.7 Average time deployed in days by branch of military subdivided by active component and reserve component........................................................................................28 FIGURE 2.8 Average dwell time in days by branch of military subdivided by active component and reserve component. .........................................................................................................28 FIGURE 4.1 Number of veterans on disability and pension payrolls by period of service. .........95 FIGURE 4.2 Total real spending on disability compensation and pensions for veterans by period of service................................................................................................................................96 FIGURE 5.1 Physical Evaluation Board process. .......................................................................121 FIGURE 5.2 VA health-care enrollment process. .......................................................................124 FIGURE 5.3 Polytrauma facility locations (levels 1 and 2). .......................................................132 BOX 5.1 Family in the Military Context .....................................................................................119 BOX 5.2 VA PTSD Programs .....................................................................................................138

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PREFACE The committee has been asked to determine the physical and mental health and other readjustment needs of members and former members of the Armed Forces who were deployed in Afghanistan in Operation Enduring Freedom (OEF) or in Iraq in Operation Iraqi Freedom (OIF) and of their families and communities. The project is a two-part study. In this first phase, the committee has focused on the readjustment issues that have been commonly reported during the last several years in the scientific literature, in government and non-governmental reports, and in the popular press to gain a broad understanding of those issues. As part of its preliminary assessment, the committee has heard from active duty service members, veterans, and family members as it made several visits around the country. The work has been humbling and eye opening. It has been gratifying to learn first-hand of the fortitude, resourcefulness, and bravery of active duty military personnel, Reserve and National Guard members, and their families. They have been proud to serve their country and if they have been wounded, physically or mentally, they expect their government to return the favor. In most cases, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) have responded to their needs admirably, but serious work remains. Because the United States is still engaged in war in Afghanistan and Iraq, the situation regarding readjustment needs is an dynamic one. The committee applauds the efforts of the DOD and the VA in trying to respond to the situation, but in some instances the response has fallen short. In going around the country, the committee gathered qualitative data. It heard the same problems repeated on the West Coast and the East Coast, in the North and South, by health care providers, by active duty service men and women, and by veterans: there are not enough mental health providers to meet the demand, case managers and providers are overwhelmed, wait times are too long for appointments and between appointments for those in need of mental health and other services, confidentiality and stigma associated with seeking care for mental illness is a significant concern of active duty service members, job training and loss of jobs due to multiple deployments are issues, the ability to diagnose and treat traumatic brain injuries is a problem, and medical care for National Guard and reserve forces is an issue as they transition between active duty and civilian life. In this preliminary report, the committee has looked broadly at the types of needs identified, including education, rehabilitation, employment training, mental health services, and other physical health services. In its second report, the committee will provide, in more detail, the extent of the services needed and will estimate costs on the basis of the services and the demographic data that it has received from the DOD and the VA. The committee could not have completed its report without the help of the many people who provided data: those in the VA and the DOD, those in the veteran service organizations, researchers, and others working in the field. In addition, the people who helped us with our town hall and other meetings—on and off base—and all those who attended those meetings provided us with an understanding of the many complex issues. xiii

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xiv PREFACE I am deeply appreciative of the expert work of our committee members and their extraordinary commitment to the task. The committee extends its appreciation to the Institute of Medicine staff. In particular we would like to thank Naoko Ishibe, Renee Wlodarczyk, and Patrick Baur, who helped with myriad tasks, including literature searches, retrieving articles, providing information for background chapters, and contributing to the development of several chapters of the report. We appreciate Joe Goodman’s attention to our meeting and travel needs and Carolyn Fulco for her guidance and oversight. George W. Rutherford, MD, AM Chair, Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and their Families

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ACRONYMS 3CM Three Component Model of Care ACAP Army Career and Alumni Program ACWV Advisory Committee on Women Veterans AFHSC Armed Forces Health Surveillance Center AFSPP Air Force Suicide Prevention Program APA American Psychological Association APFT Army Physical Fitness Test ASDHA Assistant Secretary of Defense for Health Affairs AVF All-Volunteer Force BHIE Bi-directional Health Information Exchange BHOP Air Force Behavioral Health Optimization Project BIRLS Beneficiary Identification and Record Locator System BUMED Navy Bureau of Medicine and Surgery CBO Congressional Budget Office CBOC Community Based Outpatient Clinic CDC US Centers for Disease Control and Prevention CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs CHCBP Continued Health Care Benefit Program COSC Combat Operational Stress Control CPRS Computerized Patient Record System CRS Congressional Research Service CSH Combat Support Hospital CSIS Center for Strategic and International Studies CWT Compensated Work Therapy DCHV Domiciliary Care for Homeless Veterans DCoE Defense Centers of Excellence DEERS Defense Enrollment Eligibility Reporting System DHCC Defense Health Clinical Center DMDC Defense Manpower Data Center DOD Department of Defense DOL Department of Labor DSM Diagnostic and Statistical Manual of Mental Disorders xv

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xvi ACRONYMS DTAP Disabled Transition Assistance Program DUSDMCFP Deputy Under Secretary of Defense for Military Community and Family Policy EPI Army Reserve Employer Partner Initiative ESGR Employer Support of the Guard and Reserve FAP Family Advocacy Program FAST Family Advocacy Strengths-based Therapy FRCP Federal Recovery Coordination Program FY Fiscal Year GAO Government Accounting Office GDP Gross Domestic Product HIV Human Immunodeficiency Virus HMO Health Maintenance Organization HUD Department of Housing and Urban Development HVVP Hawaii Vietnam Veterans Project IED Improvised Explosive Device IOM Institute of Medicine LOC Loss of Consciousness MEB Medical Evaluation Board MFLC Military and Family Life Counselor MGIB-AD Montgomery GI Bill Active Duty MGIB-SR Montgomery GI Bill Selected Reserve MHAT Mental Health Advisory Team MHM Military Historical Measure MHS Military Health System MOS Military Occupational Specialty MREIDL Military Reservist Economic Impact Disaster Loan MSIC Military Severely Injured Center MST Military Sexual Trauma MTF Military Treatment Facility NCA National Cemetery Administration NCSP National Call to Service Program NDAA National Defense Authorization Act NIH National Institutes of Health NIMH National Institute of Mental Health NVVRS National Vietnam Veterans Readjustment Study OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OMB Office of Management and Budget

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ACRONYMS xvii OSCAR Operation Stress Control and Readiness PCM Primary Care Manager PDH-CPG Post-Deployment Health Clinical Practice Guideline PEB Physical Evaluation Board PNS Polytrauma Network Site PPO Preferred Provider Organization PRC Polytrauma Rehabilitation Center PTSD Posttraumatic Stress Disorder RESPECT-Mil Re-Engineering Systems of Primary Care Treatment in the Military SAC School Age Care program SBA Small Business Administration SCID Structured Clinical Interview for DSM Disorders SE Supported Employment SPC Suicide Prevention Coordinator TAP Transition Assistance Program TAPS Tragedy Assistance Program for Survivors TBI Traumatic Brain Injury TR Transitional Residence UCX Unemployment Compensation for Ex-Servicemembers USD(P&R) Under Secretary of Defense for Personnel and Readiness USERRA Uniformed Services Employment and Reemployment Rights Act VA Department of Veterans Affairs VAMC VA Medical Center VBA Veterans Benefits Administration VECS Veterans Employment Coordination Service VES Vietnam Experience Study VETS Veterans’ Employment and Training Service VETSA Vietnam Era Twin Study of Aging VHA Veterans Health Administration VISN Veterans Integrated Service Network VIST Visual Impairment Service Team WWII World War II WWRC Wounded Warrior Resource Center

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