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INTRODUCTION

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The wars in Afghanistan and Iraq have been the longest sustained US military operations since the Vietnam War, although the war in Iraq formally ended on December 15, 2011. As of December 2012, Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in deployment of about 2.2 million troops; there have been 2,222 US fatalities in OEF and Operation New Dawn (OND)1 and 4,422 in OIF. The numbers of wounded US troops exceed 16,000 in Afghanistan and 32,000 in Iraq (DOD, 2012). In addition to deaths and morbidity, the operations have unforeseen consequences for military personnel that are yet to be fully understood.

In contrast with previous conflicts, the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments. Numerous reports in the popular press have made the public aware of issues that have pointed to the difficulty of military personnel in readjusting after returning from Iraq and Afghanistan. Many of those who have served in OEF and OIF readjust with few difficulties, but others have problems in readjusting to home, reconnecting with family members, finding employment, and returning to school. A recent study by the Pew Research Center (2011) notes that veterans who have major injuries resulting from their service are more than twice as likely as their noninjured counterparts to say that they have had difficulties in readjusting to civilian life. Lingering health problems related to injuries that were sustained overseas probably contribute to those readjustment difficulties. Combatrelated traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) and their potential long-term consequences also hinder readjustment.

Although the vast majority of OEF and OIF veterans believe that their military service was rewarding and had favorable outcomes (such as learning how to work with others and building self-confidence), 44% report readjustment difficulties, 48% strains on family life, 47% outbursts of anger, 49% posttraumatic stress, and 32% an occasional loss of interest in daily activities (Pew Research Center, 2011).

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1Operation Enduring Freedom (OEF) is the name for the war in Afghanistan. Operation Iraqi Freedom (OIF) is the name of the conflict in Iraq that began on March 20, 2003, and ended on December 15, 2011. On September 1, 2010, Operation New Dawn (OND) became the new name of OIF (Secretary of Defense Memorandum, February 17, 2010). The committee’s focus has been on OEF and OIF, inasmuch as no or few data on the OND deployed were available.



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1 INTRODUCTION The wars in Afghanistan and Iraq have been the longest sustained US military operations since the Vietnam War, although the war in Iraq formally ended on December 15, 2011. As of December 2012, Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in deployment of about 2.2 million troops; there have been 2,222 US fatalities in OEF and Operation New Dawn (OND)1 and 4,422 in OIF. The numbers of wounded US troops exceed 16,000 in Afghanistan and 32,000 in Iraq (DOD, 2012). In addition to deaths and morbidity, the operations have unforeseen consequences for military personnel that are yet to be fully understood. In contrast with previous conflicts, the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments. Numerous reports in the popular press have made the public aware of issues that have pointed to the difficulty of military personnel in readjusting after returning from Iraq and Afghanistan. Many of those who have served in OEF and OIF readjust with few difficulties, but others have problems in readjusting to home, reconnecting with family members, finding employment, and returning to school. A recent study by the Pew Research Center (2011) notes that veterans who have major injuries resulting from their service are more than twice as likely as their noninjured counterparts to say that they have had difficulties in readjusting to civilian life. Lingering health problems related to injuries that were sustained overseas probably contribute to those readjustment difficulties. Combat- related traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) and their potential long-term consequences also hinder readjustment. Although the vast majority of OEF and OIF veterans believe that their military service was rewarding and had favorable outcomes (such as learning how to work with others and building self-confidence), 44% report readjustment difficulties, 48% strains on family life, 47% outbursts of anger, 49% posttraumatic stress, and 32% an occasional loss of interest in daily activities (Pew Research Center, 2011). 1 Operation Enduring Freedom (OEF) is the name for the war in Afghanistan. Operation Iraqi Freedom (OIF) is the name of the conflict in Iraq that began on March 20, 2003, and ended on December 15, 2011. On September 1, 2010, Operation New Dawn (OND) became the new name of OIF (Secretary of Defense Memorandum, February 17, 2010). The committee’s focus has been on OEF and OIF, inasmuch as no or few data on the OND deployed were available. 13

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14 RETURNING HOME FROM IRAQ AND AFGHANISTAN As early as 2004, it was estimated that over one-fourth of troops returning from OEF and OIF were suffering from mental-health disorders (Hoge et al., 2004). Later estimates suggested that one-fifth of the troops reported symptoms of PTSD or depression and about the same fraction a probable TBI during deployment (Tanielian and Jaycox, 2008). Recent RAND reports note that a full one-third of returning OEF and OIF service members reported symptoms of mental-health or cognitive problems (Hosek, 2011; Tanielian and Jaycox, 2008). RAND reports that 18.5% of a representative sample of returning service members met the diagnostic criteria for PTSD or depression, 19.5% reported a probable TBI during deployment, and 7% met the criteria for a mental-health problem and TBI (Tanielian and Jaycox, 2008). PTSD is often comorbid with depression and anxiety disorders, substance-use disorders, sleep disturbances, and increased risk of suicide. Marital problems, parenting difficulties, and family-adjustment issues have also been associated with PTSD (IOM, 2008). TBI is associated with numerous long-term outcomes, including unprovoked seizures, dementia, decline in neurocognitive function, such adverse outcomes related to social function as unemployment and diminished social relationships, and depression (IOM, 2009). BACKGROUND In response to the return of large numbers of veterans from Iraq and Afghanistan with physical- and mental-health needs and to the growing readjustment needs of active-duty service members, veterans, and their family members, Congress passed Section 1661 of the National Defense Authorization Act for FY 2008 (see Appendix A). That section required the secretary of defense, in consultation with the secretary of veterans affairs, to enter into an agreement with the National Academies for a study of the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF, their families, and their communities as a result of such deployment. The study was assigned to the Institute of Medicine (IOM). The study consisted of two phases. Phase 1 was a preliminary assessment to identify findings on the physical and mental health and other readjustment needs of and on gaps in care for the members and former members of the armed forces who were deployed in OIF or OEF and their families as described in the legislation and to provide a roadmap for Phase 2. Phase 2 was to provide a comprehensive assessment of the physical, psychologic, social, and economic effects of deployment on and identification of gaps in care for members and former members, their families, and their communities. Phase 1 was completed in March 2010, and the report on it was delivered to the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the relevant committees of the House of Representatives and the Senate (IOM, 2010); Appendix B is the executive summary of the Phase 1 report. The secretaries of DOD and VA responded to the Phase 1 report in September 2010 (DOD and VA, 2010); Appendix C contains their response. The present report fulfills the requirement for Phase 2. STATEMENT OF TASK The statement of task for this study evolved out of discussions among DOD, VA, and IOM. Specifically, it was determined that in Phase 1 the IOM committee would identify

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INTRODUCTION 15 preliminary findings regarding the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed in OEF or OIF and their families. The committee was also tasked with determining the goals of Phase 2 of the study. The Phase 2 task was to provide a comprehensive assessment of the physical, mental, social, and economic effects of deployment and to identify gaps in care for members and former members of the armed forces who were deployed in OIF or OEF, their families, and their communities. The committee was directed to consider the following in its assessment:  The psychologic, social, and economic effects of deployment and of multiple deployments in OEF and OIF on service members and former members and their families.  The full scope of the neurologic, psychiatric, and psychologic effects of TBI on the members and former members of the Armed Forces and their families.  The effects of failure to diagnose such conditions as PTSD and TBI.  The long-term costs associated with TBI and PTSD and the efficacy of screening and treatment approaches for TBI, PTSD, and other mental-health conditions in DOD and VA.  The sex-specific and ethnicity-specific needs and concerns of members of the armed forces and veterans.  The particular needs and concerns of children of members of the armed forces, taking into account different age groups, effects on development and education, and mental and emotional well-being.  The particular educational and vocational needs of members and former members of the armed forces and their families and the efficacy of existing educational and vocational programs to address such needs.  The effects of deployments associated with OIF and OEF on communities that have high populations of military families, including military housing communities and townships that have deployed members of the National Guard and reserves, and the efficacy of programs that address community outreach and education concerning military deployments of community residents.  The effects of increasing numbers of older and married members of the armed forces on readjustment requirements.  Recommendations, based on such assessments, for programs, treatments, or policy remedies targeted at preventing, minimizing, or addressing the effects, gaps, and needs identified.  Recommendations, as appropriate, for additional research on such needs. COMMITTEE’S APPROACH TO ITS TASK IOM appointed a committee of 29 experts to carry out the Phase 2 study. The committee members have expertise in sociology, psychiatry, rehabilitation, neurology, economics, epidemiology, survey research, statistics, and health policy and management. A number of them also have knowledge of the workings of DOD and VA, and some are former active-duty military members. The committee divided itself into several work groups to focus on specific elements of its task: health outcomes, treatment, community effects, family issues, economics, access and barriers to care, and methods. The committee’s approach to gathering information included identifying and reviewing data in the peer-reviewed literature; reviewing government reports and testimony before

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16 RETURNING HOME FROM IRAQ AND AFGHANISTAN Congress; reviewing recent IOM reports on PTSD, TBI, and physiologic, psychologic, and psychosocial effects of deployment-related stress; gathering information directly from DOD and VA; and inviting DOD and VA researchers and officials to present data. The committee also sought input from community leaders to determine effects at the community level, conducted limited descriptive data analyses, and examined data in preexisting administrative datasets.2 Those data-gathering efforts provided the committee with a broad overview of possible readjustment needs and possible solutions related to the effects of deployment in OEF and OIF. Chapter 2 describes in more detail the committee’s approach to its task. In its attempts to understand readjustment needs, the committee conducted extensive searches of the peer-reviewed literature and considered about 3,000 articles (see Chapter 2). It also relied on the gray literature, for example, publications produced by government, business, and industry; conference proceedings; and abstracts presented at conferences. Specifically, the committee members reviewed numerous reports of the Government Accountability Office, the Congressional Budget Office, the inspectors general of VA and DOD, and the Congressional Research Service. The committee examined the basic demographic data that the Defense Manpower Data Center provided on active-duty forces, the reserve components of the military, and the National Guard, such as numbers of troops deployed, numbers of deployments, marital status, sex, and ethnicity (see Chapter 3). Those data gave the committee a basic understanding of the demographic characteristics of the deployed. The committee conducted a review of ongoing federal research efforts (Appendix D) in the areas of concern to the committee (as outlined in the legislation) to identify gaps in research. Under subcontract with Westat (a research corporation that consults on statistical design, data collection and management, and analysis), the committee conducted ethnographic research in communities affected by deployments (see Chapters 2 and 7 and Appendix E). Westat sponsored focus-group meetings with community leaders to determine the effects of returning troops on the community and to examine the effects of deployments and redeployments of reserve and National Guard units on the community. The ethnographic research provided the committee with qualitative information about short-term and long-term effects of deployments on communities. Finally, on the basis of the legislation and the committee’s discussions, its members decided to focus their findings on readjustment needs and gaps related to the conditions that are most frequently diagnosed in returning OEF and OIF active-duty personnel and veterans, such as TBI, PTSD, and other mental-health conditions, including depression, substance-use disorders, and suicidal ideation. ORGANIZATION OF THE REPORT This report is organized into 10 chapters and 6 appendixes. Chapter 2 describes the committee’s methods for gathering information, including its literature-search strategy and its ethnographic research. Chapter 3 provides information on the characteristics of the deployed and the nature of deployments on the basis of an analysis of the data that the committee obtained. 2 Administrative data collection is the set of activities involved in the collection, processing, storage, and dissemination of statistical data from one or more administrative sources; the source of data is administrative records rather than direct contact with respondents (http://stats.oecd.org/glossary/detail.asp?ID=6; accessed June 18, 2012).

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INTRODUCTION 17 Chapter 4 summarizes long-term outcomes related to TBI, PTSD, and other mental-health conditions. Chapter 5 examines the efficacy of approaches to screening for, assessment of, and treatment for TBI, PSTD, depression, substance-use disorder, suicidal ideation, and comorbid conditions. The committee reviews the clinical-practice guidelines for those conditions and reviews the scientific literature to identify current evidence-based practices. The chapter also discusses the implementation of evidence-based practices for those conditions and identifies available data for assessing quality of care. Chapter 6 explores the effects of deployment on the emotional, mental, and social well-being of family members and identifies the readjustment needs of family members (including spouses, children, and caregivers); it also discusses the availability and use of services for families. Chapter 7 addresses the effects of such deployments on communities on the basis of the literature search and rapid ethnographic assessments of selected communities. Chapter 8 examines the social and economic effects of OEF and OIF deployments on active-duty personnel, veterans, and their family members. Chapter 9 continues the discussion of treatment, focusing on access and barriers to care. Finally, Chapter 10 describes the comprehensive data analyses that the committee believes should be carried out to address unanswered questions about readjustment needs. Chapters 4 through 10 contain the committee’s recommendations as well as providing areas for future research. The committee did not prioritize the areas for future research as it hopes that the responsible agencies will carefully consider all the future research directions. This report contains several appendixes that are included in the CD inside the back cover of the report:  Appendix A—legislation outlining the committee’s tasks.  Appendix B—the executive summary of the Phase 1 report.  Appendix C—the VA and DOD secretaries’ response to the Phase 1 report.  Appendix D—summary of federal research on OEF and OIF.  Appendix E—individual ethnographic assessments.  Appendix F—database descriptions. REFERENCES DOD (Department of Defense). 2012. OEF/OIF/OND Casualty Status. http://www.defense.gov/news/casualty.pdf (accessed July 30, 2012). DOD and VA (Department of Veterans Affairs). 2010. Report to Congress Section 1661, NDAA FY2008, Phase 1 Supporting Adjustment and Readjustment of Active Military, Veterans, and Family Members: IOM's March 31, 2010 Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: Department of Defense and Department of Veterans Affairs. Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351(1):13-22. Hosek, J. 2011. How Is Deployment to Iraq and Afghanistan Affecting US Service Members and Their Families? An Overview of Early RAND Research on the Topic. Santa Monica, CA: RAND Corporation. IOM (Institute of Medicine). 2008. Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC: The National Academies Press.

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18 RETURNING HOME FROM IRAQ AND AFGHANISTAN ———. 2009. Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury. Washington, DC: The National Academies Press. ———. 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. Pew Research Center. 2011. The Military-Civilian Gap: War and Sacrifice in the Post-9/11 Era. Washington, DC: Pew Social and Demographic Trends. Tanielian, T., and L. H. Jaycox. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation.