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APPENDIX C THE DOD AND VA RESPONSE TO THE PHASE 1 REPORT C-1

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Report to Congress Section 1661 of the National Defense Authorization Act for Fiscal Year 2008 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 September 2010 C-2

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Table of Contents   I.  Introduction 1  II.  Response to IOM’s Recommendations 3  A.  IOM Recommendation 1 3  1.  DoD Response to IOM Recommendation 1 3  2.  VA Response to IOM Recommendation 1 6  B.  IOM Recommendation 2 9  1.  VA Response to IOM Recommendation 2 10  C.  IOM Recommendation 3 10  1.  DoD Response to IOM Recommendation 3 11  2.  VA Response to IOM Recommendation 3 13  D.  IOM Recommendation 4 16  1.  DoD and VA Response to IOM Recommendation 4 17  E.  IOM Recommendation 5 19  1.  DoD Response to IOM Recommendation 5 19  F.  IOM Recommendations 6, 7, and 8 20  1.  DoD Response to IOM Recommendations 6, 7, and 8 20  2.  VA Response to IOM Recommendations 6, 7, and 8 21  G.  IOM Recommendation 9 25  1.  VA Response to IOM Recommendation 9 25  H.  IOM Recommendation 10 26  1.  DoD Response to IOM Recommendation 10 26  2.  VA Response to IOM Recommendation 10 29  III.  Conclusion 31  IV.  Appendices 32  Appendix A (IOM Recommendation 1): Rigorous DoD Studies on Readjustment Needs 33  Appendix B (IOM Recommendation 1): Rigorous VA Studies on Readjustment Needs 37  Appendix C (IOM Recommendation 2): VA Long-term Management Studies 40  Appendix D (IOM Recommendation 2): VA Conference Presentations and Publications 43  Appendix E (IOM Recommendation 3): Vet Center and Mobile Vet Center Locations 44  Appendix F (IOM Recommendation 4): VA Studies - Stigmatization 47  Appendix H (IOM Recommendations 6, 7, and 8): Related VA Studies 59  Appendix I. OEF/OIF-Specific Data 69  Appendix J: Acronyms 73  C-3

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I. Introduction To address a 2008 Congressional mandate to study the physical and mental health and other readjustment needs of members and former members of the Armed Forces who deployed in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and their families as a result of such deployment (Public Law 110-181), the Institute of Medicine (IOM) of the National Academy of Sciences published Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members and Their Families on March 31, 2010. This document presents a joint response from the Secretary of Defense and the Secretary of Veterans Affairs in response to the IOM report. This report on the first phase of a two-part study describes data collection methodology, summarizes preliminary findings, and proffers ten recommendations for future research. In general, the Department of Defense (DoD ) and the Department of Veterans Affairs (VA) support the majority of IOM’s recommendations, and are pleased to report that many of the recommended actions are already well underway, with particular emphasis on OEF and OIF Service members and Veterans. In the sections that follow, comments are provided for each recommendation that include descriptions of the ongoing and completed studies and programs that address the suggested actions. Lists and brief descriptions of studies and publications are included in appendices A through H. IOM considered data from numerous sources to include:  searches of peer-reviewed literature;  data from DoD and VA;  reports from the Government Accountability Office;  reports from the Congressional Budget Office;  reports from the Congressional Research Service;  reports in the popular press;  relevant Congressional testimony;  IOM reports on PTSD, PTSD treatment, the effects of deployment-related stress, and the long-term outcomes related to TBI: and  six town hall meetings with active duty personnel, Veterans, family members, health-care providers, and community leaders. Because information on specific readjustment needs of OEF/OIF Service members, Veterans, and their families is limited, IOM included in its review reports and studies on the Service members and Veterans of the Second World War, Korea, Vietnam, and the Gulf War. The authors make it clear that direct comparisons may not be appropriate because many more Service members now survive wounds they would not have survived in earlier conflicts. C-4

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Not surprisingly, much of the data included in IOM's chapter on preliminary findings has been reported elsewhere and complete citations are provided in the text. We have culled IOM's preliminary findings for those that are specific to the OEF/OIF conflicts and have included them as appendix I. As they do in the text, the OEF/OIF-specific findings address six areas of interest to include:  TBI and related blast injuries;  polytrauma;  mental health disorders;  deployment;  women and minorities; and  projecting the lifelong burden of war. We look forward to Phase 2 of the study, “a comprehensive assessment… of the physical and mental health and other readjustment needs of members and former members of the Armed Forces who deployed in OEF or OIF and their families as a result of such deployment” (P.L. 110-181). Among the minimum requirements for Phase 2 outlined in the legislation, DoD and VA are particularly interested in new information on:  An assessment of the particular impacts of multiple deployments  An assessment of the full scope of effects of TBI and the efficacy of current treatment approaches  An estimate of the long-term costs associated with “undiagnosed” injuries such as PTSD and  “Recommendations for programs, treatments, or policy remedies targeted at preventing, minimizing, or addressing the impacts, gaps, and needs identified.” C-5

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II. Response to IOM’s Recommendations In general, the Department of Defense (DoD ) and the Department of Veterans Affairs (VA) support the majority of IOM’s recommendations, and are pleased to report that many of the recommended actions are already underway, with particular emphasis on OEF and OIF Service members. Comments are provided for each recommendation that include descriptions of the ongoing and completed studies and programs that address the suggested actions. A. IOM Recommendation 1 The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on readjustment needs of returning OEF and OIF [V]eterans, their families, and their communities that explicitly addresses methodologic and substantive gaps in completed and ongoing research. For example, the support of large-scale, independent studies with longitudinal designs, probability sampling, comprehensive clinical assessment of key outcomes, and more fully specified models that include objective biologic measures should be considered. 1. DoD Response to IOM Recommendation 1 DoD and VA agree with this recommendation and have worked steadily to develop and implement the most rigorous scientific investigations possible. In 2007, representatives from DoD, VA, various NIH (National Institutes of Health) institutes (e.g., National Institute of Mental Health [NIMH], National Institute of Neurological Disorders and Stroke [NINDS]), other federal agencies, and subject matter experts, primarily from academia, met as a working group to identify and prioritize research gaps in post-deployment military readjustment literature. This major effort directly informed the planning and development of the largest targeted research funding opportunity for deployment-related mental health and brain injury conditions in U.S. history. Supplemental Fiscal Year 2007 (FY07) DoD funding provided $150 million for Posttraumatic Stress Disorder (PTSD) research and an additional $150 million for traumatic brain injury (TBI) research. In FY09, Congress provided an additional appropriation of $55 million for psychological health (PH) and TBI research. Currently, DoD is investing more than $20.1 million in longitudinal studies on readjustment needs of Warriors and their families. One such study is described below. Study to Assess Risk and Resilience in Service Members (Army STARRS) Funded by the U.S. Army, and conducted by NIMH and an interdisciplinary team from four leading academic research institutions, this is the largest study of suicide and mental health C-6

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among military personnel ever undertaken. The research team, from the Uniformed Services University of the Health Sciences (USUHS), Harvard University, the University of Michigan, and Columbia University, is internationally known for its expertise and experience in research on military health, health and behavior surveys, epidemiology, and suicide, including genetic and neurobiological factors involved in suicidal behavior. The study will have both a retrospective and a prospective component. Investigators will undertake a retrospective case-control study, comparing Soldiers with suicidal behavior (cases) to similar Soldiers without suicidal behavior (controls) in order to identify characteristics, events, experiences, and exposures that may be predictive of Soldiers’ suicides. This study design will make it possible to begin generating information on risk and protective factors—and how to determine who is at high risk—very rapidly. Study investigators will produce actionable information that the Army can use to develop and refine interventions to prevent future suicides and address related PH issues. For the prospective study, investigators will follow a representative sample of approximately 90,000 active duty Soldiers (including mobilized Reserve Component and National Guard Soldiers), from whom they will collect detailed information on psychological and physical health, exposure to adverse events, attitudes, social supports, leadership and unit climate, training and knowledge, employment and economic status, family history, and other potentially relevant domains over the life of the study. Biological specimens (e.g., saliva and/or blood) will be collected for genetic and neurobiological studies. This will provide rich longitudinal information relating Soldiers’ characteristics and experiences to subsequent psychological health, suicidal behavior, and other relevant outcomes and will identify high-risk periods in a military career. Other Ongoing Studies In its report, the IOM comments that the “committee is aware of the Millennium Cohort study [and] several studies being conducted by RAND” (p. 156). Two of these studies are summarized briefly below. The Millennium Cohort Study (MCS) Launched in the summer of 2001, this study follows a random sample of over 150,000 U.S. military personnel from all Services, including both active duty and Reserve/National Guard members, for up to 21 years. Approximately 50 percent of the cohort has been deployed in OEF and OIF. The MCS study is designed to investigate exposures and health outcomes temporally, to detect outcomes with longer latency, and to ascertain symptom and illness duration, resolution, and chronicity. The unique aspect of this study is its ability to link this data to a wealth of DoD and VA electronic data that includes personnel files, birth and infant health, inpatient and outpatient health care use, pharmaceutical use, vaccination history, deployment C-7

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experience, exposures, and mortality. Links with other federal databases (e.g., Centers for Disease Control and Prevention [CDC], National Death Index [NDI], and Social Security Administration [SSA]) are being utilized in this ongoing study. The study is in its eighth year and current areas of research include investigations differentiated by deployment focusing on diabetes; weight change; hearing loss; migraine headaches; unit cohesion; complementary and alternative medicine and health care use; physical activity and PTSD symptoms; professional care provider occupations; PTSD and depressive symptoms; chronic multi-symptom illnesses and associated co-morbidities; motor vehicle accidents; head trauma; back pain; tendonopathies and other injuries; and cause-specific mortality including suicide. The impact of military service and deployment health on families will be evaluated through a spousal assessment component in the 2010-11 survey cycle. This study will be the first of its kind to use a large cohort to assess the impacts on spouses and co-resident children, and to evaluate the quality of family relationships.1 Funded by DoD through the Military Operational Medicine Research Program (MOMRP) and conducted at the Navy Health Research Center (NHRC) with co-investigators from all Services and VA, this large study will assess career-span health outcomes beyond military service and serve as a showcase for DoD and VA cooperation. RAND Corporation’s Deployment Life Study (DLS) The DLS is a 3-year longitudinal study that began in March 2009 to examine the impact of deployment on the health and well-being of military families. This study will recruit approximately 9,600 Army, Navy, Marine and Air Force families, following them across an OEF/OIF deployment cycle, and assessing a number of outcomes over time. These outcomes include: (i) the emotional and physical health of each family member, (ii) family relationship quality and longevity, (iii) financial well-being and role performance, and (iv) for children, school performance, and social development. The project will collect longitudinal data from approximately 5,000 (anticipated at follow-up) military families, including the Service member, his or her spouse, and, if one exists, one child 11 years of age or older (with parental consent). The baseline interview will be conducted by phone. Every 4 months after baseline, the respondent will log into a Website to complete an on- line survey. The project will take place over 36 months for nine waves of data collection, spanning a period of 6-12 months pre-deployment, throughout deployment, and post- 1 The study team estimates that 10,000 spouses will be enrolled in this component, and that about half of these will be the spouses of individuals deployed at least once to OEF and OIF. C-8

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deployment. The project will examine specific behaviors as mediators of the deployment effects, such as: accessing health care or social support services, shifts in the division of labor within the family, changes in communication patterns and style, etc. Investigators will also be able to examine how changes in some outcomes (e.g., the marital relationship) account for changes in other outcomes (e.g., child school performance). The DLS is being conducted within the RAND Center for Military Health Policy Research, a joint research initiative between RAND Health and the RAND Arroyo Center. This project is funded by the offices of the U.S. Army Surgeon General and the Assistant Secretary of Defense for Health Affairs. Appendix A lists active DoD-funded longitudinal studies on PH and TBI.2 The list includes studies from the Congressionally Directed Medical Research Programs (CDMRP) FY07 and FY09 rounds as well as other DoD funding entities and mechanisms (e.g., US Army Medical Research and Materiel Command’s (USAMRMC), MOMRP, and Telemedicine and Advanced Technology Research Center [TATRC]). 2. VA Response to IOM Recommendation 1 VA notes the following points regarding research-related limitations the Committee highlighted in the Phase I assessment:  The question of sampling is critical to validity, as the Committee noted. While samples of convenience may limit generalizability, it is more likely the case that this issue could relate to some smaller, single-site studies, although scientific peer review committees also consider generalizability carefully. Larger studies, especially those being conducted by VA's Cooperative Studies Program (CSP), address the ability to generalize as a working principle. In VA’s large-scale cohort studies, national samples considered to be representative of the population are the norm (e.g., CSP 575, a study of genetic factors related to PTSD in OEF/OIF, randomly assesses from the entire DoD manpower roster [see Appendix B).  Brief screening instruments have some utility in clinical assessments as well as in overall surveillance of a population. According to VA Office of Mental Health Services, OEF/OIF Veterans coming to VA for the first time are screened for the presence of symptoms of PTSD, depression, and alcohol abuse. The same screening for these conditions is repeated on an annual basis for new or existing Veterans of any service era. Should the Veteran screen positive for any of these conditions, further evaluation and appropriate treatment are provided. Veterans who screen positive for PTSD or 2 Some studies may appear in more than one appendix. C-9

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depression are also assessed for risk of suicidal behavior. This is important information for clinical purposes and may be legitimately reported at the level of surveillance.  In VA's research portfolio, a small number of studies have examined the validity of the screening instruments directly. However, in the more definitive large cohort studies and clinical trials, the battery of assessments is quite extensive as a rule and they are not dependent upon brief screening measures. In working group recommendations on PTSD methodology, consideration of reliability, validity, including cultural appropriateness and practicality are recommended for outcome measures. (See “Advancing Research Standards for PTSD Interventions,” 2008.)  Knowledge of VA's research portfolio will be key to further assessment by the Committee and will inform the stated limitations regarding cross sectional vs. longitudinal studies as well as focus in risk/protective factor studies. VA portfolio addresses these concerns by supporting a wide range of efforts. In some cases, specific hypotheses are being tested on a limited set of factors by design; however, in other cases, extensive batteries are used to study risk and protective factors (e.g., CSP 575). See Appendix B.  VA research program does support cross-sectional approaches in certain cases, but it is also informed by large-scale longitudinal studies. An example of this is CSP 566 (see Appendix B) with multiple post-deployment follow up assessments of an Army cohort with pre-deployment baseline performance prior to service in Iraq.  VA conducts an appreciable number of studies in the population of Veterans who have served in Iraq and Afghanistan. While some studies may rely on self-report, our Human Subjects Protection Program allows extensive oversight to ensure confidentiality and appreciation of sensitive issues. Examples include: (a) VA's consent process that includes information provided to participants stating that their participation in the research will not affect VA benefits or VA health care, (b) VA clinical researchers are encouraged to obtain a Certificate of Confidentiality, and this information is also conveyed to research participants. VA believes that scientific results from Veterans participating in VA research are not a priori tainted by this limitation. As a general operating principle, VA closely coordinates post-deployment readjustment research efforts with other federal agencies. The coordination ranges from informal phone calls between offices to co-sponsored meetings and joint solicitations. Notably, VA initially led in convening expert work groups to identify research priorities for the Veterans of Iraq and Afghanistan (see “Mapping the Landscape of Deployment Related Adjustment and Mental Disorders,” 2006). The recommendations from these work groups led to publication of multiple research solicitations focused on identified gaps. VA and NIMH have issued a series of joint solicitations on readjustment disorders in OEF/OIF Veterans, including: “Intervention and Practice Research for Combat Related Mental Disorders C-10

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and Stress Reactions,” “Network(s) for Developing PTSD Risk Assessment Tools,” and, “Clinical Pharmacotherapy for PTSD: Single and Collaborative Studies.” Both VA and NIMH committed funds for these efforts. Probably the largest interagency effort in the area of substance use/abuse co-morbidities among active duty Service members and Veterans followed discussions with multiple federal funding agencies in 2008. At a co-sponsored meeting in January 2009, VA and its federal partners set the stage for a Request for Applications (RFA) issued by VA together with the National Institute on Drug Abuse (NIDA), the National Institute of Alcohol Abuse and Alcoholism (NIAAA), and the National Cancer Institute (NCI), with a total of up to $7 million committed by all agencies. Proposals in response to this RFA will be evaluated and approved in FY 2010. A notable gap identified by the federal research funding agencies was the use of common measures and terminology for studies focused on TBI and PH. One major recent effort has therefore been collaborative work toward defining common data elements for PH and TBI. VA research with NIH’s NINDS, the National Institute on Disability and Rehabilitation Research (NIDRR), and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), co-sponsored an initiative to adopt common data elements (CDEs). Scientific experts participated in working groups for specific topic-driven CDEs, which were discussed in a workshop, “Advancing Integrated Research in Psychological Health and Traumatic Brain Injury: Common Data Elements,” held on March 23-24, 2009, with 137 national and international PH and TBI experts. The process leading to the workshop and the subsequent recommendations by the working groups led to a series of manuscripts (Overview, Agency Background, TBI Definition, TBI Demographics and Clinical Assessment, Biomarkers, TBI Neuroimaging, TBI Outcomes, PTSD, and Operational Anxiety) expected to be published in the Archives of Physical Medicine and Rehabilitation in 2010. The CDEs themselves appear on a Web site launched April 1, 2010, and hosted by NINDS (http://www.nindscommondataelements.org/). The site contains a mechanism to capture feedback and suggestions for the CDEs from the community of users. Four new working groups met in March 2010 to review and adapt the TBI CDEs for pediatric relevance. Manuscripts with recommendations are in progress. Other Methodology-Directed Activities VA has long been considered a leader in the area of PTSD research, and in 2006 co-sponsored a work group with NIMH on the topic of clinical treatment research methodology for PTSD studies (“Advancing Research Standards for PTSD Interventions,” 2008; Leon and Davis, 2009). This meeting resulted in recommendations that were disseminated widely to the scientific C-11

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Appendix H (IOM Recommendations 6, 7, and 8): Related VA Studies CONTINUED Title Amount Synopsis Proposed study to investigate: 1) the relationship between PTSD symptom severity and the components and manifestations of anger among combat Veterans; 2) the association between PTSD PTSD, Anger, symptom severity and a number of cognitive Cognition, and deficits and biases; 3) How PTSD, anger Partner Violence $435,740 dysregulation, and cognitive factors are associated Among Combat with more partner violence perpetration among Veterans combat Veterans; and 4) the hypothesis that acute exposure to trauma-related cues will potentiate associations between PTSD symptom severity and various aspects of the anger response. The Impact of Study to determine if racial differences in the rate Health Literacy on of advanced stage presentation for prostate, Racial Differences $965,736 colorectal, and lung cancer can be explained by in Cancer Stage at differences in health literacy, use of screening Presentation tests, or both. Study to: 1) estimate the relative effect of patient Assessing and cognitive, environmental, and background factors on Addressing Patient CRC screening behavior; 2) identify factors that Colorectal Cancer $816,578 contribute to any disparities in CRC screening behavior (CRC) Screening by race/ethnicity or other patient characteristics; and Barriers 3) identify from these analyses priority population subgroups to target in future interventions. Dissemination Project to adapt existing education materials to Evaluation of help Puerto Rican (PR) OEF/OIF Veterans and Educational their families readjust to life after returning home. Materials for $50,000 This project is the critical, first step in Puerto Rican accomplishing our long-range goal to improve the OIF/OEF Veterans quality of life of PR OEF/OIF Veterans/families and Families through education interventions. Our long-term goal is to improve community reintegration of OEF/OIF Veterans throughout VA Printed and Web- by creating and disseminating culturally relevant Based OEF/OIF $100,000 and low-literate, printed and web-based family Culturally- education materials. To accomplish this long-term Relevant Family goal, we plan to extend our previous work in which Education we developed family health information for Puerto Ricans in VA's Caribbean Healthcare System. C-70

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Appendix H (IOM Recommendations 6, 7, and 8): Related VA Studies CONTINUED Title Amount Synopsis Project to translate therapist and client manuals of Translation and an established theoretically-based exposure therapy Cultural for PTSD and to evaluate the cultural compatibility Adaptation of a $120,300 of the translated manualized intervention and PTSD Therapy for culturally adapt the theoretically-based, exposure Hispanics therapy intervention manuals. Telemedicine and Proposed study to expand upon previous pilot Anger findings by evaluating the clinical effectiveness of Management providing mental health services via VTC modality $840,751 Groups for PTSD as compared to the traditional in-person modality Veterans in the for Veterans with PTSD who reside in remote Hawaiian Island locations. Study testing the impact of a plain language decision aid (i.e., a low reading level) on prostate cancer patient's decision making experience as well as in their Impact of a Plain interactions with their physician and VA's health system. Language Prostate This study will also test if there are differences in receipt Cancer Decision $894,356 of active treatment between men with low vs. high Aid on Decision literacy skills and between African American and White Making men. We will also test whether the decision aid is effective both for low and high literacy patients and for African American and White men. Given that the medical-technical orientation of care at the end-of-life has been severely criticized and is considered as 'poor' quality of care by some, these A Culturally observed disparities may reflect yet another Sensitive Values- example of 'worse' care for minorities. Guided Aid for $861,762 Alternatively, it could represent true cultural, End of Life ethnic, or racial differences in decision-making for Decision-Making end-of-life care. Our study will identify these values and gain further insight into the decision- making process at the end-of-life. Study to: 1) test the feasibility of assessing and enrolling Veterans with poor health literacy and multiple co- morbid conditions, and physicians with poor communication skills to participate in the study; 2) test Improving Self- the feasibility of a one-on-one consultation between Management Veterans with low health literacy and a health educator through Facilitated $51,675 focusing on communicating about self-management.; Patient-Physician 3) simultaneously test the feasibility of a physician-based Communication communication enhancement intervention., and 4) use the pilot data to develop an investigator-initiated research (IIR) that will test the effectiveness of the interventions in a randomized clinical trial. C-71

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Appendix I. OEF/OIF-Specific Data8  TBI and Related Blast Injuries  Estimates of the percentage of OEF/OIF Service members returning with TBI range from 10 percent to 33 percent.  Some long-term outcomes are apparent at or soon after the time of injury but TBIs that have no physical signs may cause serious long-term effects that can go undetected until the Service member returns home and cannot function as before Polytrauma  Frequent co-occurring problems with TBI include o Amputation o Chronic pain o Mental health disorders (e.g., PTSD, Depression) o Polytrauma (i.e., multiple injuries, head injury or cognitive disability, and lower-limb injuries) Mental Health Disorders  Major depression o Estimates of self-reported major depression in OEF/OIF active-duty service members range from 5 percent to 37 percent  Post traumatic stress disorder o OEF/OIF Service members who experience combat exposure and those who are wounded are at higher risk than others o One 2006 government study estimated 17 percent of soldiers and 14 percent of Marines met PTSD screening criteria while deployed (other estimates vary) o Service members not identified during deployment may be identified 3-4 months (or many years) after their return Afghanistan and Iraq o MHS has spent more than $63.8 million in care and $13.1 million in prescription drugs for those with PTSD o Self-report screening, different outcome measurement, and the use of convenience samples in the extant post-deployment studies may underestimate the prevalence of PTSD and depression o Among 199 OEF/OIF Veterans referred to military behavioral health clinicians, those with PTSD or depression were five times as likely to report 888 8 Complete citations or attributions are included in the IOM chapter on Preliminary Findings. C-72

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problems with family readjustment as those who did not and almost one third of the Veterans reported that their partners were afraid of them. o There is a shortage of mental health professionals o Services available to OEF/OIF service members and veterans are poorly distributed.  Substance abuse disorder o A recent study of three Army and one Marine Corps units reported that OEF/OIF deployment was associated with higher prevalence of alcohol misuse compared to pre-deployment prevalence. o A study of reserve and National Guard reported that personnel deployed to OEF/OIF were at increased risk for new-onset heavy weekly drinking, binge drinking, and other alcohol-related outcomes. o Military deployment was associated with smoking initiation and more strongly with smoking recidivism o No data were available on drug abuse among OEF/OIF Service members Deployment o In a survey of OEF/OIF Army spouses conducted in 2004,  78 percent reported loneliness  Over 51 percent reported anxiety  Over 48 percent cited a problem with the military because of the lack of accurate information around the timing of the deployment  Over 42 percent reported depression  41 percent reported difficult in communication with the deployed member  29 percent reported difficulties in household maintenance  Over 23 percent reported fears about personal safety  21 percent reported problems with overall health  18 percent reported effects on jobs  16 percent reported problems with child care  12 percent reported financial problems  Almost 10 percent reported problems with their marriages o Few studies focus on the normative course of reintegration o One longitudinal study of reintegration during OIF reported that couples in a sample of reservists were preoccupied with relational communication and expectation, especially regarding independence, roles, and responsibilities. o Since 2003, family separation has consistently been among the top concerns of Service members stationed in Iraq and Afghanistan and is more strongly related than any other concern to mental health problems o Length of deployment appears to be positively correlated and pay grade appears to be negatively correlated with a plan for divorce on return (so far, there is little evidence that these plans are realized) C-73

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o Two small studies of OEF/OIF families suggest that symptoms of combat-related trauma are related to marital distress for both partners o No data were found on the effects of deployments on unmarried partners or the parents and other family members of Service members o The effects of OEF/OIF deployments on children who have parents deployed are consistent with those of earlier research, with studies on the current conflict reporting  Depression  Anxiety  More reactions to stress and resource losses  Academic difficulties  An increase in the use of mental health-care services o Effects on child maltreatment and intimate-partner violence are not yet known o Studies suggests that the unemployment rate of OEF/OIF Veterans may be higher than that of other Veterans o DoD's unemployment compensation costs increased 75 percent from 2002 to 2004, suggesting that OEF/OIF Veterans are having difficulty transitioning to the civilian labor market. 58 percent of the increase from 2002 to 2004 is attributed to the Army reserve components o OEF/OIF deployment reduced spousal labor-force participation almost 3 percent overall, with higher rates negatively correlated with the ages of the children. o The relationship between deployment and earnings among reservists is not clear. Women and Minorities o Although 11 percent of all personnel deployed to Iraq and Afghanistan are women, there is little research specific to that population. Among military women in general:  Over 72 percent of women in one study reported having experienced sexual harassment during their military service  63 percent reported experiences of physical and sexual harassment during military service  43 percent reported rape or attempted rape during military service  Rates of pre-military trauma are higher in women than in men; one study reported 58 percent in women versus 35 percent in men  Among civilians, women have higher rates of depression and anxiety disorders than men. Studies of military populations posted at permanent bases have yielded similar findings. o The distribution of U.S. casualties in Iraq for the first 12 months of conflict show racial equity for minorities o In the military population overall, findings of differences in service delivery or outcomes associated with race or ethnicity are inconclusive. C-74

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o Projecting the Lifelong Burden of War  Historically, the number of Veterans receiving disability and pension benefits peak several decades after the war.  As of 2008, 230,000 OEF/OIF Veterans had filed disability claims.  The majority of claims have not yet been submitted. One study suggests that 791,000 OEF/OIF Veterans will eventually seek disability benefits.  Unique aspects of OEF/OIF may result in significant deviations from historical trends (e.g., survivors of very severe injuries need more intensive care then the most severely wounded from prior wars). C-75

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Appendix J: Acronyms AF Air Force AFRTS Armed Forces Radio and Television Service AL Assisted Living ALS Amyotrophic Lateral Sclerosis BAA Broad Agency Announcements BATE Behavioral Activation and Therapeutic Exposure BCT Brigade Combat Teams CBO Congressional Budget Office CBOC Community Based Outpatient Clinic CCTA Collaborative Clinical Trial Award CDC Centers for Disease Control and Prevention CDE Common data element CDMRP Congressionally Directed Medical Research Programs CHPS Civilian Health Professions Scholarship program CNS Clinical nurse specialist COLA Cost of Living Adjustments CRC Colorectal cancer CSP VA Cooperative Studies Program CSTS Center for the Study of Traumatic Stress CTF Clinical Tracking Form DCoE Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury DES Disability Evaluation System HHS Department of Health and Human Services DLS Deployment Life Study DMDC Defense Manpower Data Center DoD Department of Defense DoDI Department of Defense Instruction DRRI Deployment Risk and Resilience Inventory DTI Diffusion tensor imaging DTM Directive-Type Memorandum DVBIC Defense Veterans Brain Injury Center ECCC Early Combined Collaborative Care ESP Evidence-Based Synthesis Project FOCUS-CI Families Over Coming Under Stress-Combat Injury FTEE Full-time equivalent employee FY Fiscal year C-76

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Appendix J: Acronyms (CONTINUED) GMT Goal management training GWVI Gulf War Veterans with illnesses GWAS Genome-wide Association Study HPO Health professions officers HSR&D Health Services Research and Development Service (VA) IAMPS International Applied Military Psychology Seminar IIR Investigator-Initiated Research IB-EW Internet based-expressive writing IOM Institute of Medicine of the National Academy of Sciences IPS Individual placement and support IPV Intimate partner violence IRB Institutional Review Board IVR Interactive voice response MA Mortuary affairs MCS Millennium Cohort Study MDR Military Health System Data Repository MHEI Mental Health Expansion Initiative Mental Health Intensive Case Management – Rural Access Network for Growth MHICM-RANGE Enhancement MHS Military Health System MOMRP Military Operational Medicine Research Program MRI Magnetic residence imagining MST Military sexual trauma mTBI Mild traumatic brain injury MTF Medical treatment facility MVC Mobile Vet Center NCI National Cancer Institute NDAA National Defense Authorization Act NDI National Death Index NHRC Navy Health Research Center NIAAA National Institute of Alcohol Abuse and Alcoholism NIDA National Institute on Drug Abuse NIDRR National Institute on Disability and Rehabilitation Research NIH National Institutes of Health NIMH National Institute of Mental Health NINDS National Institute of Neurological Disorders and Stroke NP Nurse practitioner C-77

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Appendix J: Acronyms (CONTINUED) OACT Office of the Actuary OEF Operation Enduring Freedom OHI Office of Health Administration OI&T Office of Information and Technology OIF Operation Iraqi Freedom OMHS Office of Mental Health Services OPES Office of Productivity, Efficiency, and Staffing OQP Office of Quality and Performance (VA) ORD Office of Research and Development (VA) OSD Office of the Secretary of Defense OTS Office of Telehealth Services PA Physician assistant PACT Prazosin and Combat Trauma PBRN practice-based research network PCL PTSD Checklist PCS (1) Physical Component Summary PCS (2) Post-concussion Syndrome PFCBT PTSD-Focused Cognitive Behavior Therapy PH Psychological health PHS Public Health Service PHRAMS Psychological Health Risk-Adjusted Model for Staffing PRC Polytrauma Rehabilitation Centers PRO Proactive care intervention PSA Public service announcements PT/BRI QUERI Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative PFCBT PTSD-focused cognitive behavior therapy PTSD Post traumatic stress disorder QUERI Quality Enhancement Research Initiative RC01 Research Committee 01 of the International Sociological Association RCS Office of Readjustment Counseling RCT Randomized controlled trial RFA Request for Applications R/NG Reserve and National Guard rTMS Repetitive transcranial magnetic stimulation RM Regular military SAMHSA Substance Abuse and Mental Health Services Administration SBIRT Screening, Brief Intervention, Referral and Treatment C-78

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Appendix J: Acronyms (CONTINUED) SCI Spinal Cord Injury SF-36V The Veterans Short Form 36 Questionnaire SME Subject matter expert SMI Serious mental illness SOC Senior Oversight Committee SSA Social Security Administration STARRS Study to Assess Risk and Resilience in Service Members SDQ Strengths and Difficulties Questionnaire SUD Substance use disorder T2 DCoE’s National Center for Telehealth and Technology TATRC Telemedicine and Advanced Technology Research Center TBI Traumatic brain injury TEAM Troop education for army morale TRICARE not an acronym (the military medical health system) TBIMS TBI Model Systems TLD Third-location decompression TOP Telemedicine Outreach for Post Traumatic Stress TRMD Treatment-resistant major depression UC Usual care UK United Kingdom USAMRMC US Army Medical Research and Materiel Command USDA US Department of Agriculture USUHS Uniformed Services University of the Health Sciences VA Department of Veterans Affairs VA RR&D VA Rehabilitation Research and Development Service VAMC VA Medical Center VBA Veterans Benefits Administration VetPop The Veteran Population VHA Veterans Health Administration VISN Veterans Integrated Service Network VRP Vocational rehabilitation program VSA Veterans Service Area WVHSHG Women Veterans Health Strategic Health Care Group C-79

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