Returning Home from Iraq and Afghanistan:
Assessment of Readjustment Needs of
Veterans, Service Members, and Their
Families

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

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page R1
Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families Committee on the Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families Board on the Health of Select Populations

OCR for page R1
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract HHSP23320042509XI between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-26427-3 International Standard Book Number-10: 0-309-26427-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313 http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. IOM (Institute of Medicine). 2013. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.

OCR for page R1

OCR for page R1
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org .

OCR for page R1
COMMITTEE ON THE ASSESSMENT OF READJUSTMENT NEEDS OF MILITARY PERSONNEL, VETERANS, AND THEIR FAMILIES GEORGE W. RUTHERFORD, MD, AM (Chair), Salvatore Pablo Lucia Professor and Vice Chair, Department of Epidemiology and Biostatistics; Director, Prevention and Public Health Group, Global Health Sciences, University of California, San Francisco MARGARITA ALEGRÍA, PhD, Professor, Department of Psychiatry, Harvard Medical School; Director, Center for Multicultural Mental Health Research, Cambridge Health Alliance JEFFREY J. BAZARIAN, MD, MPH, Associate Professor, University of Rochester Medical Center DAN G. BLAZER, MD, PhD, J.P. Gibbons Professor of Psychiatry, Duke University Medical Center KATHLEEN M. CARROLL, PhD, Professor of Psychiatry, Department of Psychiatry, Division of Substance Abuse, Yale University IBOLJA CERNAK, MD, PhD, ME, MHS, Chair, Canadian Military and Veterans’ Clinical Rehabilitation Medicine, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada JOHN D. CORRIGAN, PhD, Professor and Director, Division of Rehabilitation Psychology, Department of Physical Medicine and Rehabilitation, Ohio State University E. JANE COSTELLO, PhD, Professor, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine SUREYYA S. DIKMEN, PhD, Professor, Department of Rehabilitation Medicine, University of Washington NAIHUA DUAN, PhD, Professor of Biostatistics (in Psychiatry), Department of Psychiatry, Columbia University RYAN D. EDWARDS, PhD, Associate Professor of Economics, Queens College and the Graduate Center, City University of New York; Research Associate, National Bureau of Economic Research, Cambridge, MA CHRISTINE EIBNER, PhD, Economist, RAND Corporation NORAH C. FEENY, PhD, Professor, Department of Psychological Sciences, Case Western Reserve University SANDRO GALEA, MD, DrPH, Gelman Professor and Chair, Department of Epidemiology, Columbia University Mailman School of Public Health GREGORY C. GRAY, MD, MPH, Professor and Chair, Department of Environmental and Global Health, College of Public Health and Health Professions; Director, Global Pathogens Laboratory, University of Florida KENNETH W. KIZER, MD, MPH, Distinguished Professor, University of California, Davis, School of Medicine and Betty Irene Moore School of Nursing; Director, Institute for Population Health Improvement, University of California, Davis, Health System MEREDITH A. KLEYKAMP, PhD, Assistant Professor of Sociology, University of Maryland v

OCR for page R1
JANICE L. KRUPNICK, PhD, Professor of Psychiatry and Director, Trauma and Loss Program, Department of Psychiatry, Georgetown University School of Medicine RICHARD A. KULKA, PhD, Consultant, Statistical, Survey and Social Research BENNETT L. LEVENTHAL, MD, Deputy Director, Nathan Kline Institute for Psychiatric Research; Professor, Department of Disability and Human Development, University of Illinois at Chicago; Irving B. Harris Professor, Emeritus, The University of Chicago ALAIR MACLEAN, PhD, Associate Professor, Department of Sociology, Washington State University, Vancouver FRANCES MURPHY, MD, MPH, Health Care Independent Consultant, Silver Spring, MD SAMUEL J. POTOLICCHIO, MD, Professor of Neurology, Department of Neurology, George Washington University Medical Center SCOTT L. RAUCH, MD, Chair, Partners Psychiatry and Mental Health; President and Psychiatrist in Chief, McLean Hospital; Professor of Psychiatry, Harvard Medical School WILLIAM E. SCHLENGER, PhD, Principal Scientist, Abt Associates Inc. TYLER SMITH, MS, PhD, Associate Professor, Department of Community Health, School of Health and Human Services, National University Technology and Health Sciences Center S.V. SUBRAMANIAN, PhD, Professor of Population Health and Geography, Department of Society, Human Development, and Health, Harvard School of Public Health SHELLEY MACDERMID WADSWORTH, PhD, Professor of Human Development and Family Studies; Director, Center for Families; Director, Military Family Research Institute, Purdue University ALBERT W. WU, MD, MPH, Professor and Director, Center for Health Services and Outcomes Research, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health vi

OCR for page R1
STUDY STAFF CAROLYN FULCO, Scholar LAURA AIUPPA DENNING, Senior Program Officer HARRIET CRAWFORD, IT Project Manager CARY HAVER, Senior Program Associate RENÉE WLODARCZYK, Senior Program Associate DWAYNE BELL, Programmer/Analyst MARC MEISNERE, Research Associate JOE GOODMAN, Senior Program Assistant JONATHAN SCHMELZER, Senior Progam Assistant NORMAN GROSSBLATT, Senior Editor CATHERINE A. GRUBER, Editor CHRISTIE BELL, Financial Officer (until January 2012) GARY WALKER, Senior Financial Officer (until November 2012) DORIS ROMERO, Financial Associate FREDRICK ERDTMANN, Director, Board on the Health of Select Populations ANALYSTS, CONSULTANTS, AND WRITERS MARK BREWSTER, Columbia University CONNIE CITRO, National Research Council GREG COHEN, Columbia University RUTH CROSSGROVE, Independent Editor MIRIAM DAVIS, Independent Consultant PETER JAMES, Harvard University JOAN MACHAMER, University of Washington ELLEN MANTUS, National Research Council SUE MARCUS, Columbia University MARTHA PRESCOTT, Columbia University THERESA SCHWARTZ, Research Foundation for Mental Hygiene ANDREA SOLARZ, Independent Consultant JAMES WEAVER, Research Foundation for Mental Hygiene WESTAT Staff: Stephanie Beauvais, Jennifer Berktold, Diane Boyd, Mary Butler, Karla Eisen, Martha Franklin, Rachel Gaddes, Carol Hagen, Wayne Hintze, Teresa Koenig, Chris Manglitz, Shelley Perry, Cynthia Robins, and Eden Segal HEATHER YOUNG, George Washington University vii

OCR for page R1
REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following for their review of this report: Kathleen Brady, Medical University of South Carolina Alicia L. Carriquiry, Iowa State University Kenneth A. Dodge, Duke University Sanford School of Public Policy Jason Hockenberry, Emory University Rollins School of Public Health Kerry Knox, University of Rochester School of Medicine and Dentistry Thomas Kosten, VA National Substance Use Disorders Program, Quality Enhancement Research Initiative (QUERI) Captain (Retired) William P. Nash Colonel (Retired) Elspeth Cameron Ritchie, Uniformed Services University of the Health Sciences, Washington D.C. Department of Mental Health Jennifer J. Vasterling, VA Boston Healthcare System, Boston University School of Medicine Colonel (Retired) Kelly A. Wolgast, Vanderbilt University School of Nursing Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by John C. Bailar III and Harold C. Sox, Dartmouth Medical School. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution. viii

OCR for page R1
CONTENTS PREFACE..............................................................................................................................................................xi ABBREVIATIONS ............................................................................................................................................ xiii SUMMARY ........................................................................................................................................................... 1 1 INTRODUCTION ............................................................................................................................................. 13 2 METHODS ........................................................................................................................................................ 19 3 CHARACTERISTICS OF THE DEPLOYED .................................................................................................. 31 4 LONG-TERM OUTCOMES ............................................................................................................................. 47 5 SCREENING, ASSESSMENT, AND TREATMENT .................................................................................... 147 6 MILITARY FAMILIES ................................................................................................................................. .257 7 COMMUNITY IMPACTS OF DEPLOYMENT ........................................................................................... .331 8 SOCIOECONOMIC IMPACTS OF DEPLOYMENT ON SERVICE MEMBERS AND SPOUSES............ 387 9 ACCESS AND BARRIERS TO CARE .......................................................................................................... 413 10 PROPOSED DATA ANALYSES ................................................................................................................. 457 11 RECOMMENDATIONS............................................................................................................................... 471 Appendixes* A.... ............................................................................. LEGISLATION FRAMING THE COMMITTEE’S TASK B..... .....................................................................................................................................PHASE 1 SUMMARY C….. .................................................................. THE DOD AND VA RESPONSE TO THE PHASE 1 REPORT D… .. SUMMARY OF FEDERALLY FUNDED RESEARCH RELATED TO OEF AND OIF POPULATIONS E…............................................. INDIVIDUAL ETHNOGRAPHIC ASSESSMENTS OF SIX COMMUNITIES F… ........................................................................... SAMPLE OF GOVERNMENT DATA AND DATABASES * Appendixes A-F are not printed in this book but are available on the CD in the back of the book and online at http://www.iom.edu/Reports/2013/Returning-Home-from-Iraq-and-Afghanistan.aspx. ix

OCR for page R1

OCR for page R1
PREFACE In 2008, with the passage of the National Defense Authorization Act for fiscal year 2008 (PL 110-181), the National Academy of Sciences was asked to examine the readjustment needs of Operation Enduring Freedom and Operation Iraqi Freedom service members, their families, and affected communities. The Institute of Medicine assembled a committee to address the tasks in the legislation; the committee has worked for over 4 years to produce a preliminary report in 2010 and this final report. The legislation is broad and required the committee to look at many disparate issues. As the committee considered the various issues, it became apparent that it would not be able to cover all of them in depth, inasmuch as each could fill a volume. The committee had to decide which issues to focus on and which to leave for future study. It used the legislation as its guide and focused on issues related to traumatic brain injuries, posttraumatic stress disorder, and other mental-health outcomes, although pain, polytrauma, burns, and amputations are also important. The committee faced additional challenges as it approached its task. In its desire to address all aspects of its charge carefully, as required by the legislation, the committee initially tried to conduct original data analyses by linking various federal administrative datasets. There were, however, substantial organizational hurdles, and much additional time would have been required to obtain the data and conduct the analyses. The committee eventually abandoned that approach with some exceptions. To say that this study is important understates the great needs of our military men and women and their families. As we traveled the country in Phase 1 of our study, we heard from active-duty personnel, veterans, and family members and we were humbled by the sacrifices made by all of them. As we continued to read the literature, we saw that much more study would be needed, but we recognized that military personnel, veterans, and family members need answers and help now. We have all read the articles in the popular press, heard the radio broadcasts, and watched the news programs that highlight the troubling statistics regarding brain injuries, posttraumatic stress disorder, and other mental-health outcomes in our military personnel and veterans. We have read and heard about increasing marital stress, suicide, and substance abuse. We have read and heard about long wait times for appointments for treatment and disability examinations. Clearly, the nation, government agencies, communities, and families and friends need to respond. In many cases, there is a growing response, but more needs to be done to assist our active-duty military men and women, our National Guard and reserve members, our veterans, and their families. More coordination among programs is needed, more mental-health professionals are needed, and more treatments for wounds, seen and unseen, are needed. It is also necessary to reduce the stigma associated with mental illness and to reduce wait times for treatment. The Department of Defense and the Department of Veterans Affairs have made great progress in all those matters, but more will be needed—the issues will continue to plague our country for the indefinite future. xi

OCR for page R1
xii PREFACE I deeply appreciate the work of my fellow committee members and their dedication and commitment to this project, which has been in progress for several years. We extend our appreciation to the many people who helped us along the way and to the numerous consultants whom we relied on for information and data analyses. We also thank the Institute of Medicine staff directed by Carolyn Fulco for their expert assistance, in particular Harriet Crawford for her patience and for generating numerous data files for our analyses, Laura Aiuppa for her work with the family and treatment groups, Renee Wlodarczyk for leading the access and barriers group, Marc Meisnere for his work with the community group, Cary Haver for her assistance with the economics group, Jonathan Schmelzer for his willingness to help out whenever needed, and Joe Goodman for his excellent attention to detail in getting us through 10 meetings. Finally, we thank Carolyn Fulco for her overall guidance and orchestration of the multiple pieces of the study. The committee hopes that the findings in this report will result in improved outcomes for active-duty personnel, veterans, and their family members. We honor their commitment to the country, and it is for them that we persevered. George W. Rutherford, MD, AM, Chair Committee on the Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families

OCR for page R1
ABBREVIATIONS AF Afghanistan AFQT Armed Forces Qualifying Test BAI Beck Anxiety Inventory BDI Beck Depression Inventory BIRLS Beneficiary Identification records Locator System BMI body mass index BSI Brief Symptom Inventory CAPS Clinician Administered PSTD Scale CBO Congressional Budget Office CCEP Comprehensive Clinical Evaluation Program CDC Centers for Disease Control and Prevention CES Combat Exposure Scale CHCS Composite Health Care System CI confidence interval CIDI Composite International Diagnostic Interview CMI chronic multisymptom illness CNS central nervous system COD cause of death COSHPD California Office of Statewide Health Planning and Development CPG Clinical Practice Guidelines CVLT California Verbal Learning Test DCOE Defense Centers of Excellence DEERS Defense Enrollment Eligibility Reporting System DIBRS Defense Incident-Based Reporting System DMDC Defense Manpower Data Center DOD Department of Defense DSM Diagnostic and Statistical Manual of Mental Disorders DTAS Defense Theater Accountability System FY fiscal year GAO Government Accountability Office GWOT Global War on Terror ICD International Statistical Classification of Diseases IOM Institute of Medicine IZ Iraq xiii

OCR for page R1
xiv ABBREVIATIONS MCS Millennium Cohort Study MDD major depressive disorder MDP Medical SAS® Datasets MDR Military Health System Data Repository mTBI mild traumatic brain injury N number of study subjects NAS National Academy of Sciences NCIC National Crime Information Center NDE National Data Extract NDI National Death Index NIH National Institutes of Health NIMH National Institute of Mental Health NPCD National Patient Care Database OED Outpatient Encounter Database OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OND Operation New Dawn OR odds ratio PCL Patient Checklist PCL-C Patient Checklist–Civilian PCL-M Patient Checklist–Military PCS permanent change of station PDHA Post-Deployment Health Assessment PDHRA Post-Deployment Health Re-Assessment PHQ Patient Health Questionnaire PTF Patient Treatment File PTSD posttraumatic stress disorder SADR Standard Ambulatory Data Record SCID Structured Clinical Interview for DSM-II-R SF-12 12-Item Short Form Health Survey SF-36 36-Item Short Form Health Survey SIDR Standard Inpatient Data Record SMR standardized mortality ratio SSA Social Security Administration SUD substance-use disorder TBI traumatic brain injury VA Department of Veterans Affairs

OCR for page R1
ABBREVIATIONS xv VAMC VA Medical Center VBA Veterans Benefits Administration VETSNET Veterans Service Network VHA Veterans Health Administration VISN Veterans Integrated Service Network VSA Veterans Service Area

OCR for page R1