Preventing
Psychological Disorders

in Service Members and Their Families

An Assessment of Programs

Committee on the Assessment of Resiliency and Prevention Programs for Mental and Behavioral Health in Service Members and Their Families

Board on the Health of Select Populations

Laura Aiuppa Denning, Marc Meisnere, and Kenneth E. Warner, Editors

INSTITUTE OF MEDICINE
        OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Committee on the Assessment of Resiliency and Prevention Programs for Mental and Behavioral Health in Service Members and Their Families Board on the Health of Select Populations Laura Aiuppa Denning, Marc Meisnere, and Kenneth E. Warner, Editors

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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 HHSP23320080007T 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: 978-0-309-29715-8 International Standard Book Number-10: 0-309-29715-X 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 2014 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). 2014. Preventing psychological disorders in service members and their families: An assessment of programs. Washington, DC: The National Academies Press.

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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. C. D. Mote, Jr., 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. Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org .

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COMMITTEE ON THE ASSESSMENT OF RESILIENCY AND PREVENTION PROGRAMS FOR MENTAL AND BEHAVIORAL HEALTH IN SERVICE MEMBERS AND THEIR FAMILIES KENNETH E. WARNER (Chair), Avedis Donabedian Distinguished University Professor of Public Health, University of Michigan School of Public Health, Ann Arbor HORTENSIA DE LOS ANGELES AMARO, Associate Vice Provost, Community Research Initiatives and Dean’s Professor of Social Work and Prevention Medicine, University of Southern California, Los Angeles FREDERIC C. BLOW, Professor of Psychiatry, University of Michigan Medical School, Ann Arbor RAUL CAETANO, Regional Dean and Professor, University of Texas School of Public Health; Dean and Professor, School of Health Professionals, University of Texas Southwestern Medical Center, Dallas JACQUELYN CAMPBELL, Ann D. Wolf Chair and Professor, Johns Hopkins University School of Nursing, Baltimore, MD JOYCE D. ESSIEN, Retired Captain, U.S. Public Health Service; National Centers for Disease Control and Prevention; Retired Director of the Center for Public Health Practice, Rollins School of Public Health, Emory University, Atlanta, GA LISA H. JAYCOX, Senior Behavioral Scientist, RAND Corporation, Arlington, VA MARY JO LARSON, Senior Scientist, Heller School of Social Policy and Management, Brandeis University, Waltham, MA PATRICIA LESTER, Director, Nathanson Family Resilience Center, Medical Director, Child and Family Trauma Service, Jane and Marc Nathanson Family Professor of Psychiatry, University of California, Los Angeles DONALD PATRICK, Professor, University of Washington, Seattle RHONDA J. ROBINSON BEALE, Chief Medical Officer, Optum Health Behavioral Solutions, Glendale, CA M. DAVID RUDD, Provost, University of Memphis, TN NAOMI SIMON, Associate Professor, Harvard Medical School; Director, Center for Anxiety and Traumatic Stress Disorders; Director, Complicated Grief Program; Chief Medical Officer, Red Sox Foundation and Massachusetts General Hospital Home Base Program, Massachusetts General Hospital, Boston v

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Study Staff LAURA AIUPPA DENNING, Senior Program Officer MARC MEISNERE, Research Associate JOE GOODMAN, Senior Program Assistant DORIS ROMERO, Financial Associate FREDERICK ERDTMANN, Director, Board on the Health of Select Populations Consultants MIRIAM DAVIS, Independent Medical Writer, Silver Spring, MD HAROLD PINCUS, Professor and Vice Chair, Department of Psychiatry, College of Physicians and Surgeons, Columbia University; Director of Quality and Outcomes Research, New York-Presbyterian Hospital; Senior Scientist, RAND Corporation vi

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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: BRIGADIER GENERAL WILLIAM BESTER (RETIRED), Jonas Center for Nursing and Veterans Healthcare NANCY W. DICKEY, Texas A&M Health Science Center APRIL A. GERLOCK, VA Puget Sound Heath Care System ABIGAIL GEWIRTZ, University of Minnesota School of Public Health AMY M. KILBOURNE, VA Quality Enhancement Research Initiative, University of Michigan Medical School KERRY L. KNOX, University of Rochester School of Medicine Department of Psychiatry EMMANUEL MIGNOT, Stanford University School of Medicine CAPTAIN WILLIAM P. NASH (RETIRED), University of California, San Diego TRACY STECKER, Dartmouth Medical School SHELLEY MACDERMID WADSWORTH, Purdue University 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 JOHANNA T. DWYER. Appointed by the National Research Council and the Institute of Medicine, she was 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. vii

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CONTENTS PREFACE..............................................................................................................................................................xi ACRONYMS ..................................................................................................................................................... xiii SUMMARY ........................................................................................................................................................... 1 Background ....................................................................................................................................................... 1 Prevention and Good Psychological Health ...................................................................................................... 3 Psychological Health in the Military ................................................................................................................ 3 Program Evidence and Measurement ............................................................................................................... 4 Findings and Recommendations ....................................................................................................................... 4 1 INTRODUCTION ............................................................................................................................................. 9 Charge to the Committee ................................................................................................................................ 11 Committee’s Approach to Its Charge.............................................................................................................. 11 Organization of the Report.............................................................................................................................. 12 References....................................................................................................................................................... 13 2 CONCEPTUAL FRAMEWORKS FOR REVIEWING EVIDENCE-BASED PREVENTION IN PSYCHOLOGICAL HEALTH ...................................................................................................................... 15 Terminology.................................................................................................................................................... 15 Good Psychological Health............................................................................................................................. 16 Definition of Prevention ................................................................................................................................. 17 Multi-Level Prevention and the Social Ecological Model .............................................................................. 21 Application of Prevention Framework to Psychological Health for Military Members and Their Families .. 22 Prevention Within the Phases of Military Experience .................................................................................... 24 Measurement of Prevention Programs ............................................................................................................ 25 Model for Prevention Program Development and Measurement .................................................................... 29 Conclusion ...................................................................................................................................................... 30 References....................................................................................................................................................... 31 3 UNDERSTANDING PSYCHOLOGICAL HEALTH IN THE MILITARY .................................................. 35 Characteristics of the Armed Forces ............................................................................................................... 36 Psychological Health Consequences of Deployment ...................................................................................... 39 Psychological Health Among Military Families ............................................................................................. 54 Screening and Surveillance in the Military ..................................................................................................... 60 Psychological Health Services in the Military ................................................................................................ 71 Conclusions..................................................................................................................................................... 73 References....................................................................................................................................................... 74 4 EVIDENCE FOR DEPARTMENT OF DEFENSE INTERVENTIONS FOR PREVENTING PSYCHOLOGICAL DISORDERS ................................................................................................................ 85 Overview of DOD Prevention Interventions................................................................................................... 85 Resilience-Related Programs .......................................................................................................................... 86 Posttraumatic Stress Disorder ......................................................................................................................... 93 Suicide ............................................................................................................................................................ 98 Substance Use Disorders............................................................................................................................... 104 Reintegration ................................................................................................................................................. 110 Military Sexual Assault................................................................................................................................. 114 Family-Focused Programs ............................................................................................................................ 116 ix

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Conclusions................................................................................................................................................... 124 References..................................................................................................................................................... 124 5 MEASUREMENT OF DEPARTMENT OF DEFENSE PREVENTION INTERVENTIONS RELATED TO PSYCHOLOGICAL HEALTH .................................................................................................................... 135 Standards for Performance Measurement ..................................................................................................... 135 Scope of Prevention Measurement ............................................................................................................... 137 Measurement in the Military ......................................................................................................................... 137 What Should Be Measured?.......................................................................................................................... 139 Measures Identified in Review of National Quality Initiatives ..................................................................... 147 Conclusion .................................................................................................................................................... 160 References..................................................................................................................................................... 160 6 FINDINGS AND RECOMMENDATIONS.................................................................................................. 165 APPENDIXES A Summary from Returning Home From Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families .......................................................................................... 171 B Information-Gathering Meeting Agenda......................................................................................................... 183 C Supplemental Health Screening Questionnaire ............................................................................................... 187 D Pre-Deployment Health Assessment Questionnaire ....................................................................................... 191 E Post-Deployment Health Assessment Questionnaire ...................................................................................... 199 F Post-Deployment Health Re-Assessment Questionnaire ................................................................................. 211 G Program Reviews from Substance Use Disorders in the U.S. Armed Forces................................................. 221 H Table of DOD Programs to Increase Resilience or Prevent Psychological Health Disorders, as Identified by RAND ................................................................................................................................. 273 x

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PREFACE Military personnel and their families confront numerous challenges to their psychological well-being. While many are similar to the stresses experienced by people not in the military, others derive from circumstances unique to the service members’ professional station in life. Particularly for military personnel deployed in conflict situations overseas—including the hundreds of thousands who have served in Afghanistan and Iraq—physical and psychological traumas, such as those experienced in combat, can produce debilitating and sustained mental health burdens. The problems originating in overseas deployments often are visited upon the families of the service men and women as well, first because they have to adjust to an uncertain and worrisome life without their spouse or parent, and then because they have to readjust once the service member returns home. The Department of Defense (DOD) recognizes that, in addition to addressing the physical injuries that members of the military experience as a result of their service, it has a responsibility to help military personnel and their families who develop various mental and behavioral problems. Such problems include posttraumatic stress disorder, the sequelae of traumatic brain injury, drug abuse (including abuse of alcohol, prescription drugs, and illicit drugs), intimate partner violence and child abuse, and suicidal ideation. Previously, the department requested assistance from the National Academy of Sciences (NAS) to evaluate the readjustment needs of returning service members and their families. The Institute of Medicine (IOM) committee appointed to fulfill that assignment chose to focus on the psychological and behavioral problems and to report on how the military should proceed in order to address these problems most effectively. That multi-year study led to publication of a report titled Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families, published by the National Academies Press in 2013. More recently, DOD asked NAS to assess the quality and evidence base of programs in DOD designed to prevent negative psychological health outcomes among service members and their families and to identify appropriate performance measures for such programs. The IOM assembled a committee of experts to address this task. The committee interpreted its assignment as evaluating whether there were opportunities, extant or to be developed, to prevent psychological and behavioral problems altogether or to more effectively—and more preemptively—mitigate the effects of psychological health problems as they were emerging. The expertise of the committee was wide-ranging, including members who have devoted their careers to studying the military’s approach to addressing behavioral and psychological health problems, with a special interest in prevention. Others have focused on the implications of military service on the health of families, and several committee members have expertise in the psychological health areas addressed in this study, including suicide and suicidal ideation, substance abuse disorders, and interpersonal violence. With a focus on prevention, the committee reviewed hundreds of publications, policy directives, and other documents pertaining to DOD’s many programs to identify and address mental health problems among military recruits, active duty personnel, and, to a lesser extent, military veterans. The committee met in Washington, DC, on four occasions, examining and xi

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xii PREFACE evaluating material on these programs with the objective of assessing the nature and depth of DOD’s commitment to prevention as well as the effectiveness of the department’s many relevant interventions. The committee sought to assist the department in determining how it can use scarce resources to optimize its efforts, through prevention, to protect and restore the mental and behavioral health of its personnel and their families. The committee’s findings and recommendations, presented in this report, address these objectives directly. Some findings and recommendations address rather specific issues, such as how DOD can select appropriate metrics for evaluating programmatic interventions. Others relate to more systemic concerns, such as the need for effective oversight to ensure that DOD’s prevention-related resources are used in an effective and cost-effective manner. An overriding concern is how to identify, develop, implement, and continually evaluate evidence-based interventions to promote psychological health. A fundamental finding of the committee is that, with some notable exceptions, few of DOD’s prevention interventions are theory- or evidence- based. The level of knowledge and insight that committee members brought to the committee’s deliberations was essential to the development of an informed report. The members’ diligence and devotion to the task, and the congeniality with which they engaged in this effort, made a very challenging assignment a surprisingly pleasurable one. I am most grateful to them. I would also like to thank Harold Pincus, whose consultation to the committee regarding performance measurement proved invaluable as the committee deliberated on the subject. The committee benefited immensely from the outstanding and seemingly tireless work of the IOM professionals assigned to staff this project. From seeking out information and data and organizing that information and data for the committee’s use, to offering their own insights during our discussions and drafting much of the report, the IOM staff members deserve the lion’s share of the credit for the committee having produced its report on schedule. The staff members deserve, as well, much of the credit for the quality and usefulness of the report; however, those characteristics may be assessed by those who will consult it. In particular, the committee expresses its deep gratitude to Laura Aiuppa Denning, IOM senior program officer and this study’s director; Marc Meisnere, research associate; and Joe Goodman, senior program assistant. The committee hopes that its work will prove useful to DOD and to others concerned with the psychological health and welfare of the Americans who volunteer to put their lives on the line for the benefit of our country. These men and women deserve nothing less. Kenneth E. Warner, Chair Committee on the Assessment of Resiliency and Prevention Programs for Mental and Behavioral Health in Service Members and Their Families

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ACRONYMS ACE Ask, Care, Escort AHRQ Agency for Healthcare Research and Quality ARMY STARRS Army Study to Assess Risk and Resilience in Servicemembers ASD acute stress disorder ASIST Applied Suicide Intervention Skills Training BOOT STRAP Bootcamp Survival Training for Navy Recruits—A Prescription CBT cognitive behavioral therapy CISD critical incident stress debriefing CoRC Culture of Responsible Choices COSC Combat Operational Stress Control CRIS Community Reintegration for Injured Service Members CRS Congressional Research Service CSF Comprehensive Soldier Fitness DAPA drug and alcohol program advisor DHA Defense Health Agency DOD Department of Defense EPTS existed prior to service FAP Family Advocacy Program FOCUS Families OverComing Under Stress FWV Futures Without Violence FY fiscal year GAO Government Accountability Office GAT Global Assessment Tool HHS Department of Health and Human Services HRA Health Risk Appraisal IOM Institute of Medicine IPV interpersonal violence MC&FP Military Community and Family Policy MEPS Military Entrance Processing Stations MFLC Military and Family Life Consultant MHS military health system MORE My Ongoing Recovery Experience MST military sexual trauma xiii

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xiv ACRONYMS NAS National Academy of Sciences NBHQF National Behavioral Health Quality Framework NORTH STAR New Orientation to Reduce Threats to Health from Secretive Problems That Affect Readiness NQF National Quality Forum OCMO Office of the Chief Medical Officer OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OSCAR Operational Stress Control and Resilience OSD Office of the Secretary of Defense PCL–C PTSD Checklist–Civilian PCM primary care manager PCMH Patient-Centered Medical Home PDHA Post-Deployment Health Assessment PDHRA Post-Deployment Health Re-Assessment PEC Pharmoeconomic Center PreDHA Pre-Deployment Health Assessment PREP Prevention and Relationship Enhancement Program PTSD posttraumatic stress disorder RESPECT–Mil Re-Engineering Systems of Primary Care Treatment in the Military SAMHSA Substance Abuse and Mental Health Services Administration SAPR Sexual Assault Prevention Response SBIRT Screening, Brief Intervention, and Referral to Treatment SUD substance use disorder TBI traumatic brain injury TLD third location decompression USAF U.S. Air Force USPSTF U.S. Preventive Services Task Force VA Department of Veterans Affairs WARCAT Warrior Administered Retrospective Casualty Assessment Tool WWCTP Wounded Warrior Care and Transition Policy YRRP Yellow Ribbon Reintegration Program