5

SCREENING, ASSESSMENT, AND TREATMENT

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In this chapter, the committee assesses the approaches used in the Department of Defense (DOD) and Department of Veterans Affairs (VA) to identify service members and veterans with neurologic or psychologic health conditions and treat them. The committee reviews health screening and assessment practices and treatment interventions for six conditions that can affect readjustment after military deployment: traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), major depressive disorder (MDD), substance-use disorders (SUDs), suicidal ideation, and comorbid conditions. Their assessment relies on clinical and scientific evidence to examine the efficacy of approaches that DOD and VA use in the management of those conditions.

The committee reviewed the clinical practice guidelines (CPGs) developed jointly by VA and DOD1 and compared them with clinical guidelines developed by leading scientific and professional organizations. CPGs are statements and recommendations for clinical care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options (IOM, 2011a). The committee also reviewed the research and policy literature as a basis for discussing standard-of-care recommendations that are presented throughout this chapter.2

The committee acknowledges that the presence of clinical guidelines does not ensure that people receive optimal evidence-based care. Poor dissemination practices and other barriers affect the extent to which clinicians use CPGs (Stein et al., 2009). The committee examined the sparse data available to address the question of whether military members and veterans actually receive evidence-based interventions offered in the VA and DOD health systems. Our inquiries to VA and DOD did not yield much about results of using clinical performance measures, metrics that are designed for assessing and monitoring clinical processes or patient outcomes.

The committee became aware of a few sources of clinical performance measures relevant to VA’s monitoring of mental-health care delivery and discusses this information in each section. For example, the VA Office of Quality and Performance contracts with an external agency to

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1Under the auspices of the VA/DOD Evidence Based Practice-Guidelines Work Group, representatives of VA and DOD serve on committees for developing, updating, and implementing joint CPGs for a number of physical- and mental-health conditions. VA/DOD joint guidelines exist for TBI, PTSD, MDD, and SUD but not for suicidal ideation and comorbid conditions.

2The literature review concentrated on new studies since publication of the CPGs and on synthesized analyses of randomized controlled trials.



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5 SCREENING, ASSESSMENT, AND TREATMENT In this chapter, the committee assesses the approaches used in the Department of Defense (DOD) and Department of Veterans Affairs (VA) to identify service members and veterans with neurologic or psychologic health conditions and treat them. The committee reviews health screening and assessment practices and treatment interventions for six conditions that can affect readjustment after military deployment: traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), major depressive disorder (MDD), substance-use disorders (SUDs), suicidal ideation, and comorbid conditions. Their assessment relies on clinical and scientific evidence to examine the efficacy of approaches that DOD and VA use in the management of those conditions. The committee reviewed the clinical practice guidelines (CPGs) developed jointly by VA and DOD1 and compared them with clinical guidelines developed by leading scientific and professional organizations. CPGs are statements and recommendations for clinical care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options (IOM, 2011a). The committee also reviewed the research and policy literature as a basis for discussing standard-of-care recommendations that are presented throughout this chapter.2 The committee acknowledges that the presence of clinical guidelines does not ensure that people receive optimal evidence-based care. Poor dissemination practices and other barriers affect the extent to which clinicians use CPGs (Stein et al., 2009). The committee examined the sparse data available to address the question of whether military members and veterans actually receive evidence-based interventions offered in the VA and DOD health systems. Our inquiries to VA and DOD did not yield much about results of using clinical performance measures, metrics that are designed for assessing and monitoring clinical processes or patient outcomes. The committee became aware of a few sources of clinical performance measures relevant to VA’s monitoring of mental-health care delivery and discusses this information in each section. For example, the VA Office of Quality and Performance contracts with an external agency to 1 Under the auspices of the VA/DOD Evidence Based Practice-Guidelines Work Group, representatives of VA and DOD serve on committees for developing, updating, and implementing joint CPGs for a number of physical- and mental-health conditions. VA/DOD joint guidelines exist for TBI, PTSD, MDD, and SUD but not for suicidal ideation and comorbid conditions. 2 The literature review concentrated on new studies since publication of the CPGs and on synthesized analyses of randomized controlled trials. 147

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148 RETURNING HOME FROM IRAQ AND AFGHANISTAN conduct monthly standardized medical-record reviews of outpatient care as part of the External Peer Review Program and uses the data to monitor according to national performance measures. In addition, much of the data on implementation and monitoring of evidenced-based practices included in this chapter comes from an independent evaluation of the quality of VA mental- health and substance-use care. VA commissioned the RAND Corporation and Altarum Institute to perform the evaluation, which they conducted between 2006 and 2010 (Watkins and Pincus, 2011). The study was authorized by the Government Performance and Results Act of 1993 and Title 38 of the US Code, which require independent evaluations of large government programs. In general, studies have shown that the health care that VA provides for a number of conditions, such as diabetes and heart disease, is on par with or better than care provided in non-VA settings (Jha et al., 2003; Trivedi et al., 2011). However, as discussed in this chapter, VA’s performance in mental health is not as strong, given the variation found among service networks and the low rate of delivery of some evidence-based practices (Watkins et al., 2011). DOD has an extensive centralized Military Health System–wide database for population health management called the Military Health System Population Health Portal.3 However, clinical performance measures in the dataset do not address mental-health care. In 2010, the Defense Health Board recommended to the assistant secretary of defense for health affairs that “evidence-based metrics for processes of mental health care” should be developed and monitored to address questions of mental health care quality and adequacy of clinical capacity/resources (Defense Health Board, 2010). The Defense Health Board added that DOD should evaluate clinician competence in providing evidence-based treatment and patience adherence to treatment. As VA and DOD continue to advance their efforts to evaluate mental-health care services, they face a number of challenges, such as the lack of validated clinical performance measures that assess the full array of psychologic health services and the lack of appropriate benchmarks that VA and DOD can use to compare their performance. Measurement of clinical performance is not as advanced in mental health as it is in other types of care (Pincus et al., 2011; Watkins et al., 2010). That potentially presents opportunities for VA and DOD to collaborate with each other and with others in the field to advance clinical performance measurement aimed at improving the quality of mental health care and care for brain injury. ORGANIZATION OF THE CHAPTER The chapter is organized in six main sections: TBI, PTSD, MDD, SUDs, suicidal ideation, and comorbid conditions. By structuring the chapter according to each condition, the committee does not mean to suggest that it is always the case that a single diagnosis can account for all symptoms or that a single set of clinical guidelines and evidenced-based treatments will address all symptoms. Many patients, particularly in military settings, present with complex problems that do not fall neatly into single diagnostic categories. Comorbid, co-occurring, and dual diagnosis are terms used to indicate that more than one disorder is occurring in the same person, simultaneously or sequentially, and that associated interactions between the illnesses affect the course and prognosis of each. This chapter uses the terms comorbid and co-occurring. 3 The Military Health System Population Health Portal contains administrative health care data on TRICARE Prime/Plus enrollees who receive care through military treatment facilities and contracted providers.

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SCREENING, ASSESSMENT, AND TREATMENT 149 Each section presents screening, assessment, and treatment interventions. In this chapter, screening refers to a process for identifying people who may be at risk for a specific disease that uses tests (or screening instruments), examinations, or other procedures. Screening instruments are helpful for identifying people who might have a disease but are not very useful for assessing progression, prognosis, or treatment efficacy (IOM, 2006). A person who has positive screening results should be referred for assessment by a medical professional for diagnosis and treatment. Assessment refers to a process for defining the nature of a problem, determining a diagnosis, and developing recommendations for addressing the problem or diagnosis (SAMHSA, 2009). Within the discussion of screening, assessment, and treatment, the chapter describes the VA and DOD clinical guidance and practices used in the management of the selected conditions. The chapter often refers to screening processes achieved in the US military during the deployment cycle—the predeployment health assessment, the Post-Deployment Health Assessment (PDHA), and the Post-Deployment Health Re-Assessment (PDHRA) (Terrio et al., 2011). Predeployment health assessments are administered at home stations or at mobilization processing stations before deployment. The PDHA is conducted 3–10 days after deployment, and the PDHRA 90–180 days after deployment. On return from deployment, service members are required to complete assessment forms that ask about their deployment history and that screen for a number of physical and psychologic conditions, including TBI, PTSD, MDD, SUDs, and suicidal ideation. Health care providers followup with all service members on completion of the forms to make referrals to appropriate health care or community-based services if further evaluation or treatment is needed. For each health condition, there is a discussion of the evidence underlying the validity of the screening and assessment instruments used by VA and DOD health practitioners. A review of treatment interventions includes a comparison of the VA and DOD recommended practices with recommendations in other relevant CPGs. Finally, we present information available on the extent to which VA and DOD are implementing evidenced-based interventions for screening, assessment, and treatment. TRAUMATIC BRAIN INJURY A TBI is the result of a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. In 2007, DOD formally defined TBI as a “traumatically induced structural injury or physiological disruption of brain function as a result of an external force” (DCoE, 2012e). Such an injury may range from “mild”—a brief change in mental status or consciousness—to “severe,” an extended period of unconsciousness or amnesia after the injury. The terms concussion and mild TBI are used interchangeably. See Chapter 4 for a full definition of TBI and for details about its prevalence in the military and veteran populations. Numerous symptoms are associated with mild TBI, including headaches, dizziness, fatigue, inability to concentrate, memory problems, irritability, balance problems, vision change, and sleep disturbance. Most people who sustain a mild TBI usually recover completely with minimal intervention. A TBI classified as moderate or severe can result in short-term or long- term problems with independent function (IOM, 2009). As discussed in Chapter 4, TBIs of all severities, including a small fraction of mild cases, are known to be associated with adverse long-term neurologic outcomes, such as seizures, cognitive dysfunction, and neurodegeneration. The military emphasizes early assessment for TBI on the battlefield in recognition that delayed

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150 RETURNING HOME FROM IRAQ AND AFGHANISTAN diagnosis might be detrimental to a service member’s health and combat readiness (DOD, 2010b; Helmick, 2011). To assess the efficacy of current screening and treatment approaches for mild TBI, the committee examined a number of clinical guidelines and DOD and VA policy directives for TBI. This section’s emphasis is on mild TBI, inasmuch as such cases are the most common and the most frequently underrecognized and undertreated. Department of Defense and Department of Veterans Affairs Guidance for Screening for Mild Traumatic Brain Injury Detecting mild TBI close to the time of injury is best for preventing symptoms, optimizing care, and improving outcomes; however, mild TBI can be difficult to identify. The rigor of combat operations and lack of observable head trauma may delay assessment. In addition, identifying a head injury often relies on self-reported symptoms, but service members may be reluctant to report symptoms because they do not want to be separated from their unit and wish to avoid any stigma associated with psychologic or psychiatric services. Moreover, the frequent presence of comorbid conditions, such as PTSD, complicates recognition of mild TBI based on symptoms alone. DOD and VA have system wide screening and assessment procedures in place at multiple points of care to identify mild TBI in service members. A positive screen indicates the need for further evaluation to diagnose a TBI. Diagnosis cannot be made on the basis of a positive screening test alone. Department of Defense In DOD, service members may be screened for TBI in a theater of combat operations, in MTFs, and on return from theater (postdeployment). In addition to screening, DOD requires all service members to undergo a baseline neurocognitive assessment before deployment. Neurocognitive Testing Neurocognitive testing helps to determine the degree of cognitive impairment after head injury. In 2006, a DOD expert panel concluded that neurocognitive assessment is an important part of a TBI evaluation (DVBIC, 2006). In May 2008, DOD issued guidance requiring each service to implement baseline predeployment neurocognitive assessment for service members with the Automated Neuropsychological Assessment Metrics (ANAM) tool (Casscells, 2008a). Developed, tested, and implemented by DOD, the ANAM is a computer-based assessment of cognitive functions likely to be affected by a concussion, including attention, concentration, reaction time, memory, processing speed, and decision making (DVBIC, 2006). The ANAM is not used as a TBI screening tool itself but serves as a baseline with which a post-TBI evaluation can be compared. Service members take the predeployment neurocognitive assessment within 12 months of deployment. Injured service members can be given a second ANAM test in theater, which should be administered 24–72 hours after injury if possible, and the results are compared with the original test scores to look for changes in cognitive function (DCoE, 2011b). DOD policy does not require that all service members receive a postdeployment neurocognitive assessment, such as one with the ANAM, but recommends that care providers in

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SCREENING, ASSESSMENT, AND TREATMENT 151 theater consider postinjury neurocognitive testing as a component of the comprehensive TBI evaluation and return-to-duty assessment (DCoE, 2011b; GAO, 2011). Screening in Theater and in Medical Facilities During deployment, service members are screened for possible TBI, whether on the basis of self-reported symptoms or an event that occurred. In 2006, the Defense and Veterans Brain Injury Center (DVBIC) recommended screening service members in military operational settings (DVBIC, 2006); in the following year, the Army required screening of service members who were exposed to a blast or other injury event and had associated loss of consciousness, amnesia, or alteration in mental status, however brief (DVBIC, 2007). In June 2010, DOD broadened the screening criteria: all service members exposed to a “mandatory event”—regardless of initial symptoms—are screened for TBI and required to rest for 24 hours (DOD, 2010b). Mandatory events are defined as being in a vehicle associated with a blast, collision, or rollover; being within 50 m of a blast; a direct blow to the head or witnessed loss of consciousness; or command-directed, especially in a case with multiple blast events. The 24-hour rest period is mandatory regardless of the results of TBI screening (DOD, 2010b). DOD’s TBI screening tool, the Military Acute Concussion Evaluation (MACE), is suitable for use in theater and in medical facilities. The DVBIC developed the MACE in conjunction with national experts in sports concussion. The MACE has history and evaluation components. The history component can confirm the diagnosis of mild TBI after it is established that trauma has occurred and that the service member experienced an alteration in consciousness. The evaluation component, designed to be used easily by medics and corpsmen in combat theater, consists of a symptom inventory and a brief assessment of neurocognitive deficits in four domains: orientation, immediate memory, concentration, and delayed recall (DVBIC, 2006, 2008a; French et al., 2008). The MACE is also used to screen wounded service members who are evaluated in tactical medical units that provide Level III care (resuscitative care, stabilization, and hospitalization), such as the Air Force Theater Hospital in Balad, Iraq, or in definitive care (Level IV) regional medical facilities outside the area of operations, such as the Landstuhl Regional Medical Center in Germany (these two types of facilities have somewhat different procedures for following up a positive screen). Of stateside inpatient MTFs that provide comprehensive care (Level V), only Walter Reed National Military Medical Center was conducting TBI screening since 2007 (DOD, 2010b). Postdeployment Screening In 2008, DOD started routine screening of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members for TBI immediately on their return from the combat theater and again 3–6 months after return as part of the required PDHA and PDHRA process (briefly described at the beginning of this chapter). Routine screening was not implemented until 2008, so many service members have never been screened for mild TBI (Iverson et al., 2009). The TBI screen used in the DOD health assessments is a modified version of the Brief Traumatic Brain Injury Screen (BTBIS) (Schwab et al., 2007), which was validated by further research and adapted for use in the PDHA and PDHRA (Terrio et al., 2011). Returning service members report responses to four screening questions about exposure to an injury event, the later

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152 RETURNING HOME FROM IRAQ AND AFGHANISTAN loss of or alterations in consciousness, the presence of symptoms at the time of injury, and the presence of current symptoms (see questions in Box 5.1). A positive response regarding at least one problem in each of the four questions means that the screen is positive. A service member who has a positive screen is referred for a full TBI evaluation (Helmick, 2011). BOX 5.1 TBI Screening Questions in DOD’s PDHA and PDHRA 9.a. During this deployment, did you experience any of the following events? (Mark all that apply.) 1. Blast or explosion (IED, RPG, land mine, grenade, etc.) 2. Vehicular accident/crash (any vehicle, including aircraft) 3. Fragment wound or bullet wound above your shoulders 4. Fall 5. Other event (for example, a sports injury to your head). Describe: 9.b. Did any of the following happen to you, or were you told happened to you, IMMEDIATELY after any of the event(s) you just noted in question 9.a.? (Mark all that apply.) 1. Lost consciousness or got “knocked out” 2. Felt dazed, confused, or “saw stars” 3. Didn’t remember the event 4. Had a concussion 5. Had a head injury 9.c. Did any of the following problems begin or get worse after the event(s) you noted in Question 9.a.? (Mark all that apply.) 1. Memory problems or lapses 2. Balance problems or dizziness 3. Ringing in the ears 4. Sensitivity to bright light 5. Irritability 6. Headaches 7. Sleep problems 9.d. In the past week, have you had any of the symptoms you indicated in 9.c.? (Mark all that apply.) 1. Memory problems or lapses 2. Balance problems or dizziness 3. Ringing in the ears 4. Sensitivity to bright light 5. Irritability 6. Headaches 7. Sleep problems SOURCE: DOD, 2008.

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SCREENING, ASSESSMENT, AND TREATMENT 153 Department of Veterans Affairs In April 2007, VA started screening all OEF and OIF veterans who were receiving medical care in the Veterans Health Administration (VHA) for TBI; those who screen positive are offered further evaluation and treatment by clinicians who have expertise in TBI (VA, 2010c; VA and VHA, 2007). VHA’s screening tool, the Traumatic Brain Injury Screening Instrument (TBISI), has four questions based on the BTBIS, the tool designed for active-duty military personnel (Carlson et al., 2010); see questions in Box 5.2. BOX 5.2 TBI Screening Questions in VA’s TBISI Section 1: During any of your OEF and OIF deployment(s), did you experience any of the following events? (Check all that apply.) 1. Blast or explosion 2. Vehicular accident/crash (including aircraft) 3. Fragment wound or bullet wound above shoulders 4. Fall Section 2: Did you have any of these symptoms IMMEDIATELY afterwards? (Check all that apply.) 1. Losing consciousness/ “knocked out” 2. Being dazed, confused or “seeing stars” 3. Not remembering the event 4. Concussion 5. Head injury Section 3: Did any of the following problems begin or get worse afterwards? (Check all that apply.) 1. Memory problems or lapses 2. Balance problems or dizziness 3. Sensitivity to bright light 4. Irritability 5. Headaches 6. Sleep problems Section 4: In the past week, have you had any of the symptoms from section 3? (Check all that apply.) 1. Memory problems or lapses 2. Balance problems or dizziness 3. Sensitivity to bright light 4. Irritability 5. Headaches 6. Sleep problems SOURCE: GAO, 2008. The screening process for TBI (see Figure 5.1) is executed as part of the VHA automated clinical reminder system used by clinicians at its medical facilities (Carlson et al., 2010). An

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154 RETURNING HOME FROM IRAQ AND AFGHANISTAN OEF or OIF veteran who reports having received a TBI diagnosis at some point is offered a referral; a veteran who reports no prior TBI diagnosis during deployment is asked to answer the four screening questions. The screen is positive if the veteran says yes to any response item in each of the four questions (GAO, 2008). A veteran who had a positive screen is offered a followup evaluation with a specialty provider at a specified medical center. VA clinicians have to document any refusal of specialty care in the veteran’s electronic medical record (VA, 2010c). FIGURE 5.1 Flow chart for VHA screening and evaluation of possible traumatic brain injury in OEF and OIF veterans. SOURCE: VA, 2010c.

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SCREENING, ASSESSMENT, AND TREATMENT 155 Validity of Tools for Neurocognitive Assessment and Screening for Mild Traumatic Brain Injury Automated Neuropsychological Assessment Metrics A 2010 comprehensive review of the DOD ANAM program, prepared by the Army’s Office of the Surgeon General, states that the lack of clear scientific evidence supporting ANAM’s effectiveness raises important questions about whether DOD is using the best available technology to assess cognitive function after head injury (Department of the Army, 2010a). Research data raise questions about the accuracy of the ANAM for detecting cognitive dysfunction—and recovery from this dysfunction—after mild TBI. In one study, among 956 soldiers returning from Iraq or Afghanistan, a history of self- reported mild TBI or current postconcussive symptoms was not associated with poor ANAM performance (Ivins et al., 2009). In another study, 502 service members recently deployed to Iraq or Afghanistan who had self-reported TBI and predeployment and postdeployment ANAM testing were compared with 400 service members who had no history of TBI. The two groups performed similarly on predeployment testing. Of the entire group that reported TBI during deployment, 70% had no significant change in cognitive performance compared with their baseline ANAM test (Roebuck-Spencer et al., 2012). Research is under way to address questions about the ANAM (see Appendix D). This is an important subject of study because ANAM scores are being used to inform return-to-duty decisions. Military Acute Concussion Evaluation Used both in theater and in medical facilities, the MACE is the most widely used TBI screen in DOD; however, there is some concern that it might fail to detect a large proportion of service members’ concussions. Embedded in the MACE is the Standardized Assessment of Concussion (SAC), a brief cognitive screening tool developed to assess the acute effects of sports-related mild TBI. The SAC has demonstrated reliability, validity, sensitivity, and specificity in athletic cohorts (McCrea et al., 2003). The MACE, however, when administered more than 12 hours after injury in a military setting and compared with a clinical diagnosis of concussion, had a sensitivity of only 51% (specificity 64%) when a cutoff score of 27 was used. At the suggested cutoff score of 25, the sensitivity was even less at 20% (specificity 88%) (Coldren et al., 2010). Research is under way to determine the validity of this tool at earlier times and to attempt to improve its accuracy through comparison with predeployment scores (see Appendix D). Brief Traumatic Brain Injury Screen Initial research with the BTBIS postdeployment TBI screen suggested that it was a reasonably accurate screening tool for TBI. In 2007, the BTBIS was administered to 596 soldiers returning from Iraq or Afghanistan and compared with two longer surveys—the Quarterly Survey and the Computerized TBI Questionnaire—that were used to elicit a history of TBI. The BTBIS had a sensitivity of 90% when compared with the Quarterly Survey and 88% when compared with the Computerized TBI Questionnaire. It had a specificity of 88% when compared with the Quarterly Survey and 97% when compared with the Computerized TBI Questionnaire (Schwab et al., 2007).

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156 RETURNING HOME FROM IRAQ AND AFGHANISTAN However, a 2011 study suggested that the false-negative rate of the DOD postdeployment TBI screen—which was adapted from the BTBIS—was high. Its four questions were compared with a brief structured clinical interview for mild TBI in 3,072 soldiers who were returning from a 15-month tour of duty in Iraq. The sensitivity and specificity of the DOD screening tool (positive response to all four items) were 60% and 96%, respectively. The sensitivity increased to 80%, with a slight decrease in specificity to 93%, when affirmative responses only to questions 1 and 2 were included. Thus, omission of the last two questions significantly reduced the false-negative rate from 40% to 20% (Terrio et al., 2011). Traumatic Brain Injury Screening Instrument Research on the accuracy of the TBISI, the screening tool used by VA, is emerging (VA, 2012). The Government Accountability Office (GAO) emphasized the need for empirical evidence on the sensitivity and specificity of the VA TBI screening instrument in a 2008 report (GAO, 2008). A 2010 study revealed that the test–retest reliability of the VHA postdeployment TBI screen was low. In 44 OEF and OIF veterans referred for neuropsychologic evaluation after a positive TBI screen, agreement was low between answers to the original TBI screen and rescreening 6 months later for mechanism of injury and symptoms immediately after injury but high for current symptoms (Van Dyke et al., 2010). A recent psychometric study of the TBISI involving 500 OEF and OIF veterans concluded that the instrument appears to be reliable and valid. The results showed high internal consistency (0.77) and test–retest reliability (0.80), high sensitivity (0.94), and moderate specificity (0.59) (Donnelly et al., 2011). Implementation of Department of Defense and Department of Veterans Affairs Guidance for Screening for Mild Traumatic Brain Injury This section presents information available to the committee on the extent to which DOD and VA are implementing and tracking screening procedures to identify possible TBI. The committee identified various sources of information but notes the lack of readily available centralized sources of data, particularly within DOD, on the numbers of people who are screened and have a positive screen. Department of Defense Neurocognitive Testing More than 1 million service members had received neurocognitive tests as of September 30, 2011 (DCoE, 2012a). The ANAM is not Web-enabled, and data are not stored in a centralized database; therefore, summary statistics comparing ANAM scores before and after injury are not available. Screening in Theater and in Medical Facilities Over 9,000 soldiers have been screened for mild TBI in theater since August 2010 (Department of the Army, 2012). An article in the popular press reported that from January to September 2011, nearly 1,400 service members had screened positive in Afghanistan and Iraq as part of the new mandatory evaluation requirements that broadened the screening criteria (Zoroya, 2011). DOD policy requires the documentation of all service members who were exposed to potential concussive events and the development of a medical quality-assurance program and

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SCREENING, ASSESSMENT, AND TREATMENT 157 metrics to track implementation of TBI screening procedures (DOD, 2010b). In response, US Central Command developed an automated reporting module called the Blast Exposure and Concussion Incident Report, but data have yet to be publicly released (USMedicine.com, 2012). An article in Military Medicine raised concern about the quality of screening implementation, stating that “there is no standardized training or evaluation of administration competence on the MACE for medical providers in Iraq” (Coldren et al., 2010). Postdeployment Screening During FY 2009 and 2010, 2% of service members who were returning from tours of duty screened positive for TBI on the PDHA, and 4% on the PDHRA (DOD, 2012). In a study of 7,909 marines of the First Marine Expeditionary Force who were returning home during 2004– 2006, 9% screened positive on the BTBIS. It appears that the investigators considered only responses on the first two questions of the screen. Of those who screened positive for TBI, 70.5% (500) were first identified with the screen (Drake et al., 2010). Department of Veterans Affairs VA measures the rates of TBI screening of all veterans returning from Iraq and Afghanistan who present for medical care; the VA’s Office of Quality and Performance (OQP) has set a target of screening 95% of all veterans (Sayer, 2009). From April 2007 to November 2012, over 644,000 veterans have been screened for TBI. This represents approximately 95% of those eligible for screening. Through July 2012, 127,901 (20%) of OEF/OIF/OND veterans have screened positive for TBI (Sayer, 2012). Department of Defense and Department of Veterans Affairs Guidance for Assessment and Diagnosis of Mild Traumatic Brain Injury There is no biologic “gold standard” for diagnosing mild TBI. On the basis of a positive TBI screen test, further clinical evaluation is needed to make a diagnosis. Department of Defense In DOD, the level of the medical care facility determines the nature of the assessment. In Level I and II facilities in theater, MACE screening results are used to determine the disposition of service members. Those who screen negative can return to active duty after 24 hours of rest. Those who screen positive receive concussion education or management of symptoms and can return to duty when they are asymptomatic at rest and then asymptomatic after exertion but no sooner than 24 hours after injury. Service members who receive a diagnosis of a second concussion in a 12-month period must rest for 7 days. Service members who suffer three or more concussions in a 12-month period cannot return to duty until a Recurrent Concussion Evaluation is completed by a neurologist or other qualified licensed provider who is knowledgeable about concussion. The evaluation includes the Neurobehavioral Symptom Inventory, the Acute Stress Disorder Questionnaire, a vestibular assessment, and neurobehavioral testing (no specific instrument is recommended). Neuroimaging (with computed tomography [CT] or magnetic resonance imaging) and a functional assessment are initiated at the discretion of the health care provider (DOD, 2010b).

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