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TRICARE Beneficiaries and Mental Health Issues in Military Families

This chapter addresses the characteristics of the TRICARE beneficiary population and the mental health issues that they face. It begins with a brief summary of the demographics of the population and a discussion of their special exposures, risk factors, and protective factors. Information on mental health disorders follows, focusing on the conditions identified in the committee’s statement of task and on psychosocial issues for US military families. The chapter concludes with a presentation of data on patients under the care of counselors.

The intent of the chapter is to provide background information on patients that might be seen by mental health professionals who deliver diagnostic and treatment services to TRICARE beneficiaries.

DEMOGRAPHICS OF THE TRICARE POPULATION

TRICARE submits yearly reports of its operations to Congress that include details on the demographics of its beneficiary population. That information is summarized below.

In 2008, TRICARE served a population of 9.4 million beneficiaries (TRICARE, 2009). The 8.8 million who reside or are stationed in the United States are divided into three regions—North, South, and West—that provide care to roughly equal proportions of that population (HealthNet Federal Services, 2009; Humana Military Healthcare



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2 TRICARE Beneficiaries and Mental Health Issues in Military Families T his chapter addresses the characteristics of the TRICARE benefi- ciary population and the mental health issues that they face. It begins with a brief summary of the demographics of the popula- tion and a discussion of their special exposures, risk factors, and protec- tive factors. Information on mental health disorders follows, focusing on the conditions identified in the committee’s statement of task and on psychosocial issues for US military families. The chapter concludes with a presentation of data on patients under the care of counselors. The intent of the chapter is to provide background information on patients that might be seen by mental health professionals who deliver diagnostic and treatment services to TRICARE beneficiaries. DEMOgRAPHICS OF THE TRICARE POPuLATION TRICARE submits yearly reports of its operations to Congress that include details on the demographics of its beneficiary population. That information is summarized below. In 2008, TRICARE served a population of 9.4 million beneficia- ries (TRICARE, 2009). The 8.8 million who reside or are stationed in the United States are divided into three regions—North, South, and West—that provide care to roughly equal proportions of that popula- tion (HealthNet Federal Services, 2009; Humana Military Healthcare 

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Services, 2009; TriWest, 2009). The remaining beneficiaries—about 0.6 million—are covered in overseas regions. Only about 20% of beneficiaries are active-duty members of the armed forces or activated members of the National Guard or Reserves; 26% are family members (including children) of active-duty or activated personnel, and 54% are retirees and their families (TRICARE, 2009). Almost half the beneficiaries are female (48.5%). Figure 2.1 shows the beneficiary population’s age diversity. Appendix B contains additional demographic and socioeconomic information about the general military population (including families) and the Operation Iraqi Freedom (OIF) and Operation Enduring Free- dom (OEF) warfighters. The data there are intended to provide more background on the similarities and differences between the TRICARE population and other managed–health-care populations. SPECIAL ExPOSuRES AND RISK FACTORS IN THE TRICARE POPuLATION Military life presents a number of exposures and risk factors that may influence the likelihood of experiencing a mental health problem. Different factors affect different segments of the beneficiary population. They are discussed below to highlight some of the issues that must be considered in evaluating the readiness of practitioners to provide diag- noses to and treat the population. 25% Males 20% Females 15% 10% 5% 0% ≤4 ≥65 5-14 15-17 18-24 25-34 35-44 45-64 Age range FIguRE 2.1 Age distribution of the TRICARE beneficiary population. NOTE: Percentages shown are percentages for each sex, not the whole beneficiary population. SOURCE: TRICARE (2009). FIGURE 2-1

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES Combat Exposure and Traumatic Stressors Combat exposure is one of the greatest stressors that a person can experience. In theater, combat veterans report frequent encounters with roadside improvised explosive devices (IEDs), suicide bombers, snipers, and an omnipresent insurgence characterized by an inability to differ- entiate combatants from noncombatants. Patrol operations may entail attacking, being attacked, killing, and witnessing mutilations and other carnage. OIF and OEF troops report distress over ethical violations to be a central problem (MHAT, 2006). Although most soldiers and marines reported receiving adequate battlefield-ethics training, over one-fourth reported encountering situations in which they did not know how to respond (MHAT, 2006). Feelings of helplessness and guilt may fuel the experience of emotional turmoil and depression. Multiple deployments, longer deployments, and the constancy of a 24/7 threatening living environment characterize tours of duty. A state of anxiety interferes with sleep (a major protective factor in survival) and erodes resilience. A sample of service members who had been deployed to OIF or OEF reported exposure to a wide array of traumatic events; 50% noted that they had a friend who was killed or seriously wounded, and 45% saw people who were dead or seriously wounded (Tanielian and Jaycox, 2008). In a study conducted by Hoge et al. (2004), 2,586 Army and 815 Marine Corps combat infantry troops were interviewed and completed postdeployment surveys. During their tours of duty in Iraq, 92% were attacked or ambushed; 95% received small arms fire; 94% saw dead bodies or human remains; 89% received artillery, rocket, or mortar fire; 86% knew someone who was killed or seriously injured; and 56% reported being responsible for the death of an enemy combatant. Research indicates that TRICARE may experience a relatively high volume of OIF and OEF veterans seeking treatment for posttraumatic stress disorder (PTSD) in the coming years. A team of researchers with the San Francisco Department of Veterans Affairs (VA) Medical Center discovered a time lag in reporting of mental health problems among OIF and OEF veterans—up to 2 years postservice (Seal et al., 2009). The data point to a need for providers, not only in the VA system but in TRICARE, to be prepared for waves of OIF and OEF veterans and their family members seeking mental health and psychosocial services. Research findings generated by Charles Hoge and his team at the Walter Reed Army Medical Center Research Center suggest that spouses

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE manifest rates of mental health problems similar to those in soldiers; TRICARE probably also needs to be prepared to respond to mental health issues presented by family members (Eaton et al., 2008). Active-duty servicewomen face some unique experiences during their deployments. They participate in a wide array of duties and have experienced comparable exposure to combat (IOM, 2008). Female service members face issues related specifically to physical violence, sexual harassment, and assault. Over the last 2 decades, there has been increasing attention to violence and sexist harassment against female service members. The emphasis on strong masculine traits, the war culture, the devaluing of feminine traits, and sexual slurs increase the risk of victimization of women (Donohoe, 2005). In a convenience sample of 270 female veterans, 33% reported experiencing a sexual assault during their service in the military (Surís et al., 2004). Women who reported rape or dual victimization (both rape and other forms of violence) were more likely also to report chronic health problems, prescription drug use for emotional problems, failure to complete college, and annual income less than $25,000. Women who reported dual traumas also reported the most severe impairment (Sadler et al., 2000). In a more recent study conducted by Street et al. (2008), the coinvestigators discovered a high prevalence of sexual harassment and assault and rates higher among female service members. Such victim- ization was associated with not only more immediate physical and mental health effects but long-term health-care needs. Higher rates of PTSD in women are statistically associated with increasing rates of military sexual assault. In a meta-analysis of 21 papers, Goldzweig et al. (2006) reported rates of sexual harassment of 55–99% and rates of sexual assault of 4.2–7.3% in active-duty women compared with 11–48% in female veterans. The noteworthy disparity in reported rates can be partially explained by victimized active-duty soldiers’ fear of retaliation, especially if the offenders were superior officers or if allegations had been countered with censure. Issues for Military Families and Retirees Demographic data compiled by the Department of Defense (DOD, 2007a) show that 57.7% of active-duty service members have family responsibilities; that is, they have spouses, one or more children, or other

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES dependents. The demographic profile of Reserve and National Guard families is similar. As in society at large, the health of a military family is influenced by the health of the service member, and the health and productivity of the service member are integrally related to and enhanced by the health and welfare of the family. Military occupation and duties involve a variety of stressors. They include a mobile lifestyle, isolation from the civilian community and extended family, adjustment to the rules and regula- tions of military life, and frequent family separations due to frequent deployments. In addition, stressors for female spouses are complicated by worries about jobs, child rearing, and household duties while male service members are deployed. Along similar lines, the male partner of a deployed female service member may encounter difficulties in adjust- ing to new roles in caretaking and management of the home. For single mothers, added stress is related to the enlisting of family members, friends, or hired child-care workers to provide care for their children during deployment. In general, if the nondeployed civilian partner of a service member finds military life stressful or unsatisfactory, the service member also becomes dissatisfied and more likely to leave the military (Eaton et al., 2008). Eaton and colleagues found, in their study of 940 spouses of service members deployed to Iraq or Afghanistan, that spouses reported types and magnitudes of mental health problems similar to those of the service members and that spouses were more likely to seek mental health services for those problems. Spouses did not seem to be as concerned about the stigma of mental health care as service members. Spouses most often sought and received care from their primary-care physicians; this may be related to the lack of mental health services for spouses on military installations. A DOD Task Force on Mental Health report indicated that mental health services for spouses are not adequately provided through the TRICARE insurance network (DOD, 2007b). Much attention has been given to the needs of service members and spouses, but many military families are concerned about having adequate mental health resources for their children, especially school-age and adolescent youth. Parental concerns expressed, in addition to facilitating typical childhood development, include parenting skills to manage fre- quent deployments, reintegration and reentry programs when the service member returns to the family, addressing anxiety and fears experienced by children with regard to the deployed parent, managing multiple moves, and bereavement support (National Military Family Association, 2006).

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Retirees make up a substantial portion of the TRICARE beneficiary population. Many of them are also veterans. Among the veterans seeking care, depression is one of the most common chronic conditions treated in VA Medical Centers (Cully et al., 2008). That may be the result of untreated mental health conditions incurred during military service or independent of military service. Retirees may be coping with the loss of a spouse or managing chronic or long-term illness other than mental health problems. Other studies have shown that veterans have higher rates of alcohol misuse, which is often associated with depression (IOM, 2008). Risk Factors The greatest risk factors for mental health problems during deploy- ment include higher intensity of exposure to combat stressors; greater length of deployment; female sex; lower socioeconomic status; lower rank; absence of peer, social, and family supports; and a history of child- hood trauma1 (IOM, 2008). One major risk factor associated with the onset of PTSD is physical injury. In a study of returning OIF veterans conducted by Hoge et al. (2007), those who were physically injured had 3 times as great a risk of developing PTSD, regardless of the severity of the injury, as the non- injured. The incidence of PTSD increases significantly with the number of injuries suffered. Rates of PTSD and major depression were highest among Army sol- diers, Marines, and those who were no longer on active duty (people in the Reserves and those discharged or retired from the military). Women, Hispanics, and enlisted personnel were more likely to report symptoms of PTSD and major depression; the best predictor of these conditions was exposure to combat (Tanielian and Jaycox, 2008). Protective Factors Many service members arrive home fortified by their resilience and reintegrate into their communities without adverse mental health effects. Pride and a sense of accomplishment often prevail. In consid- In contrast, however, Yehuda and colleagues report that managing the legacies of 1 childhood traumatic events provides a combat soldier with a sense of protective mastery and efficacy (Yehuda et al., 2006).

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES ering resilience, it is important to recognize the important influences of protective factors that mediate the effects of adverse events. First, constitutional hardiness often refers to the “healthy-soldier effect” based on physical fitness and psychological readiness to assume an assertive, active, coping style. Second, during all phases of the deployment cycle, service members who have experienced the most comprehensive train- ing, strong leadership, unit cohesion, and an esprit de corps are buffered against adverse health effects. In reservists and members of the National Guard, in particular, navigating assignments to a new unit and estab- lishing new connections may undermine resilience. Third, a validating and supportive homecoming is also important. Research points to the centrality of family and social supports as major protective factors (Friedman, 2006). The social supports include loved ones; immediate- family and extended-family members; work colleagues; members of a church, mosque, or temple; support networks for military partners and families; and a wide array of health-care and mental health–care providers. Such positive social supports serve as vital buffers against the emergence of mental health problems. “Signature” Mental Health and Psychosocial Issues Unlike Vietnam-era veterans, for whom PTSD was the prominent adverse mental health outcome, veterans of recent conflicts report high rates of various distinct yet interrelated syndromes, including PTSD, depression with suicidal ideation and behavior, substance misuse and abuse, and traumatic brain injury (TBI). Milliken and colleagues (2009) found that when service members who had returned from Iraq were rescreened about 6 months after an initial assessment, they reported more adverse mental health concerns and were referred for care at sig- nificantly higher rates; this suggests that some problems take time to manifest after deployment. A 2008 Institute of Medicine (IOM) report focused on the physi- ological, psychological, and psychosocial effects of deployment-related stress. Findings revealed “sufficient evidence” of a positive association between deployment to a war zone and a number of specific health outcomes in studies in which chance and bias, including confounding, could be ruled out with reasonable confidence. The outcomes included psychiatric disorders, including PTSD, other anxiety disorders and depression; alcohol abuse; accidental death in the years after deployment;

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE suicide in the early years after deployment; and heightened marital and family conflict, such as intimate-partner violence (IOM, 2008). Thus, military personnel returning from deployment in Iraq and Afghanistan—a part of the TRICARE beneficiary population that may have high demand for services—may present with a complex array of mental health and substance-use problems and psychosocial difficulties. Because many syndromes involve symptoms that mirror other mental and physical health diagnoses, advanced skills in differential clinical diagnosis are required to work with this client population. Box 2.1 contains a fictitious vignette2 featuring a returning OIF veteran viewed in the context of his partnership, family, and social environment. The diagnosis and course of treatment presented are intended to highlight the complexity and acuteness of the physical, psy- chological, and psychosocial issues confronted by clinicians who deliver services through TRICARE. This case is delineated in greater detail in Appendix F. MENTAL HEALTH CONDITIONS IDENTIFIED FOR ATTENTION BY THE TRICARE MANAgEMENT ACTIvITY The committee’s statement of task—spelled out in Chapter 1—lists several health outcomes that were identified for special attention by the TRICARE Management Activity. The sections below provide back- ground information on them and briefly summarize their signs and symptoms, incidence, and recognized treatments. They are intended to provide context for understanding issues related to the diagnosis of and treatment for disorders that may be found in the TRICARE benefi- ciary population. In reviewing this text, it is important to consider that these conditions can co-occur in a person and make treatment needs complex. More complete descriptions of the diagnostic criteria and etiol- ogy of these conditions are contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM). A table in Chapter 5 (Table 5.3) lists examples of evidence-based psychosocial interventions for many of these disorders. The case was adapted and expanded from a clinical vignette contained in Basham 2 (2009).

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES BOx 2.1 Case vignette—Sergeant Arrozo Kathryn Basham, PhD, LICSW (Member of the Committee) Sergeant Carlos Arrozo, a 30-year-old Army OIF veteran of Puerto Rican descent, returned home after a 12-month tour of duty with second- and third-degree burns to his arms and face and a broken pelvis as a result of an IED blast. After his homecoming, he reunited with his 29-year-old wife of 10 years and his three young children, all under the age of 10 years. Although the reunion brought great relief and pride to the family, within 6 weeks Sgt. Arrozo started to experience pervasive anxiety, insomnia, and nightmares. Flashbacks of horrific combat experi- ences of violent actions were often triggered by smells of burning rubber, sights of men and women cloaked in heavily layered garments, sounds of cars backfiring, and visions of a vast expanse of sand blowing on the beach. Such events stimulated an intense traumatic stress response that activated arousal that alternated with numbness and detachment; this was consistent with posttraumatic stress and/or PTSD. Sgt. Arrozo’s affect was totally dysregulated. When his wife, Maria, and children experienced terror during these episodes, they would retreat to safety as quickly as possible by hiding in distant rooms throughout the house or garage. Fighting ensued between the marital partners, with Sgt. Arrozo yelling at his children when they failed to follow his directives quickly enough. He sought refuge by drinking eight beers four or five times each week with his buddies and did not view this level of alcohol intake as a problem. His home environment was characterized by fear, uncertainty, and detachment combined with pervasive anxiety in everyone involved. After receiving a medical discharge based on his physical injuries, PTSD, and depression, Sgt. Arrozo felt plagued by the impending threat of divorce, joblessness, and obsessional thoughts related to his “accidental killing” of a young child during combat. Sadness and unrelenting guilt overwhelmed him as he battled traumatic grief and depression, and they reactivated unresolved mourning surrounding his mother’s death from cancer when he was 8 years old. In his words, Sgt. Arrozo felt “tense, continued

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE BOx 2.1 Continued distractible, agitated, irritable, enraged and numb” most of the time. Those symptoms not only are compatible with a diagnosis of PTSD but suggested syndromes of depression, substance abuse, or TBI. For example, sleeping poorly and suffering nightmares and headaches and then grogginess in the morning may be related to PTSD, or they could be related to depression, substance abuse, or TBI. The differential diagnosis of Sgt. Arrozo’s distress leads to a complex nexus of PTSD, depression, TBI, substance abuse, and family conflict. When Sgt. Arrozo agreed to seek mental health assistance, his wife telephoned to get access to a mental health provider authorized by TRICARE. After receiving the name of a nonmedical licensed mental health clinician, Sgt. Arrozo was invited to attend an individual session to embark on an assessment. After a 1-hour meeting, a preliminary diag- nosis of PTSD and depression was established on the basis of a patient self-report. To help Sgt. Arrozo to find rapid relief from his combat- related psychological injuries, the clinician referred him to a colleague for prolonged exposure therapy and recommended meeting for 1 hour each week to address his symptoms of depression. The latter treatment plan included psychoeducation related to PTSD and depression and the use of cognitive-behavioral skills to track his depressed mood through journaling. Sgt. Arrozo could not concentrate on his daily writing assign- ments and felt ashamed of his incapacity to improve. After 3 weeks of the combined treatment plan, flooding of emotions from the exposure therapy overwhelmed him, and he decompensated, reporting many sui- cidal thoughts. He terminated the therapy. Major Depressive Disorder Major depressive episodes are characterized by symptoms (Table 2.1) that are persistent and interfere with a person’s daily living, functioning, and interactions with others (NIMH, 2009b). The episodes are not the result of normal bereavement due, for example, to the death of a loved one. Major depressive disorder (also known as major depression) is diag- nosed when a person experiences one or more major depressive episodes

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES Was Sgt. Arrozo a failure, or were there unintended iatrogenic effects that were based on the absence of a thorough biopsychosocial assessment and differential diagnosis? Did the clinician fail to attend to the totality of this veteran’s struggles and to explore areas in his social context (a faith-based community or cultural traditions, for example)? Were Sgt. Arrozo’s competences, resilience at work and school, and mili- tary leadership skills explored and affirmed? Apparently, his undiagnosed mild TBI interfered with his benefiting from a cognitive-behavioral method that requires reasonably sound functioning. Finally, the absence of attunement to the volatile relationship between the marital partners and between the parents and children set the stage for increasing decom- pensation and further destabilization. Was a risk assessment completed to determine the safety or lack of safety in this home? Are there aspects of intimate-partner violence that are concealed? Are the children expressing symptoms of secondary trauma evidenced by heightened insecurity? The treatment provided to Sgt. Arrozo and his family revealed vari- ous problems. They included an incomplete biopsychosocial assessment, inattention to safety risks, an inadequate treatment plan, the absence of collaboration with other providers, and lack of attunement to socio- cultural influences. The complexity of the issues facing Sgt. Arrozo and his family requires strong clinical expertise that would permit a complex and detailed biopsychosocial assessment, including structured clinical interviews; the use of standardized clinical measures; and collaboration with other health professionals followed by a phase-oriented, relational, culturally responsive, and evidence-based practice plan. A complete case summary of Sgt. Arrozo and his family is available in Appendix F. with no history of manic symptoms. It is often an episodic illness, but persons with major depression can also experience chronic depressive symptoms (Judd et al., 1998). The lifetime prevalence of major depression in the United States is nearly 17% (Kessler et al., 2005). In a study by Lapierre et al. (2007) of Iraq and Afghanistan war veterans, 37 and 38%, respectively, reported symptoms of depression. Hoge et al. (2004) found that 7.1–7.9% of troops returning from Iraq met criteria for depression and were

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Employment, Finances, and Homelessness A previous IOM (2008) research effort concluded that there was inadequate evidence to determine whether an association exists between deployment and homelessness and adverse employment outcomes. That conclusion may have been driven by the dearth of methodologically rig- orous studies available at the time. More recent anecdotal reports of the transitions of OEF and OIF veterans suggest increasing difficulty with financial stability, employment, and housing (MHAT, 2006). Because social supports remain the major protective factors in mediating adverse mental health outcomes while also promoting healing, attention should be focused on the social contexts of service members and their families during any phase of clinical intervention. DATA ON PATIENTS uNDER THE CARE OF COuNSELORS In the statement of task, TRICARE requested that the committee review and synthesize available data on the proportions of all patients who had a series of specified disorders and were under the care of licensed mental health counselors. The committee requested those data from the TRICARE Management Activity; the information listed in Table 2.16 is derived from its response to the request. It is important to note sev- eral limitations of the information. The table provides estimates of the numbers of cases treated in the TRICARE population, but for several reasons it probably does not reflect the true prevalences of the disorders. The gold standard for determining diagnoses is the structured clinical interview or chart review. The information in Table 2.16 was obtained from administrative data based on usual care practice, which often does not include structured diagnostic interviews by clinicians and therefore can be less accurate. Research shows that accuracy of claims data can vary by diagnosis. For example, administrative data have demonstrated relatively high accuracy for bipolar disorder (Unutzer et al., 1998, 2000) and schizophrenia (Lurie et al., 1992) but lower accuracy for depression (Spettel et al., 2003). In addition, this information reflects only the primary (or first) diagnosis entered in an insurance claim; if a patient presented for treatment and the mental and substance-use (M/SU) condition was not listed first (e.g., depression and SUD or hypertension and generalized anxiety), the condition would not be included in the table. Therefore, the table likely underrepresents the prevalence of these

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 TRICARE BEnEFICIARIES AnD MEnTAL HEALTH ISSUES TABLE 2.16 Patients in the Care of Mental Health Counselors in the Military Health System TRICARE Beneficiaries with Diagnosis During FY 2008 Seen by Mental Seen by Health Counselor Mental Health (% of enrollees Total Counselora with M/SU Diagnosis (n) (n) diagnosis) Major depressive disorder 204,078 10,480 5.1 Schizophrenia 4,335 182 4.2 Posttraumatic stress disorder 36,526 2,484 6.8 Bipolar disorder 40,970 2,573 6.3 Mental health disorder related to 9,681 144 1.5 a general medical condition Somatoform disorder 529 9 1.7 Delirium 586 1 0.2 Dementia 1,042 8 0.8 Amnestic disorder 188 3 1.6 Substance-use disorder 66,067 974 1.1 Traumatic brain injury 38,159 11 0.03 Data may include providers who have different levels of licensure, certification, a education, and experience. SOURCE: TMA (2009). disorders in the treatment-seeking TRICARE population. Finally, the table does not capture the complexity of co-occurring medical, M/SU, and psychosocial problems that are often seen in this population. Information provided to the committee indicates there were 9,197,927 TRICARE beneficiaries in FY 2008 (TMA, 2009). However, the data in Table 2.16 excludes TRICARE for Life participants because TRICARE is not their primary payer. Enrollees in the six designated provider plans are also excluded. This reduces the overall number of ben- eficiaries for whom outcomes are reported in the table to 7,217,566. The committee attempted to identify and obtain other available data on the proportions of patients who had various diagnoses and were under the care of licensed mental health counselors. However, such data are not present in the scientific literature and are not routinely compiled

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE by care providers.6 Even if they were, the weaknesses in the TRICARE data identified above suggest that they would be of little utility in evaluating the ability of counselors to provide services to the TRICARE beneficiary population as independent practitioners. REFERENCES Alderfer BS, Arciniegas DB, Silver JM. 2005. Treatment of depression following traumatic brain injury. Journal of Head Trauma Rehabilitation 20(6):544-562. Alvarez L. 2008. Despite Army assurances: Violence at home. new york Times, November 23, 2008, 24. Andreski P, Chilcoat H, Breslau N. 1998. Post-traumatic stress disorder and somatization symptoms: A prospective study. Psychiatry Research 79(2):131-138. Annegers JF, Hauser WA, Coan SP, Rocca WA. 1998. A population-based study of seizures after traumatic brain injuries. new England Journal of Medicine 338(1):20-24. APA (American Psychiatric Association). 2000. Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association. Basham K. 2009. “Commentary on the keynote lecture presented by Dr. Jonathan Shay, Friday, June 27, 2008, titled ‘The trials of homecoming: Odysseus returns from Iraq/Afghanistan, and additional reflections.’” Smith College Studies in Social Work 79(3&4):299-309. Bell N. 2009. Health and occupational consequences of spouse abuse victimization among male U.S. Army soldiers. Journal of Interpersonal Violence 24(5):751-769. Bremner JD, Southwick SM, Darnell A, Charney DS. 1996. Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. American Journal of Psychiatry 153(3):369-375. Brown PJ, Stout RL. 1997. Six-month posttreatment outcomes of substance use disordered patients with and without comorbid PTSD. Paper presented at the annual meeting of the Inter- national Society for Traumatic Stress Studies, Montreal, Ontario, Canada. Brown PJ, Recupero PR, Stout R. 1995. PTSD substance abuse comorbidity and treatment utilization. Addictive Behavior 20(2):251-254. Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. 2007. Prevalence of depression-PTSD comorbidity: Implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine 22(6):711-718. Campbell JC, Garza MA, Gielen AC, O’Campo P, Kub J, Dienemann J, Jones AS, Jafar E. 2003. Intimate partner violence and abuse among active duty military women. Violence Against Women 9(9):1072-1092. Some researchers have examined the proportion of patients in the general population 6 (Wang et al., 2005, 2006) or particular demographic groups (Neighbors et al., 2006) under the care of psychiatrists versus nonpsychiatrists, but these publications do not differentiate counselors from other nonpsychiatrist providers.

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