Provision of Mental Health Counseling Services Under TRICARE (2010)

As noted in Chapter 2, the TRICARE beneficiary population is a far larger and more diverse population than the active-duty personnel who might come to mind first when one is considering the mental health risks and needs of a military population. This appendix presents details on the demographic and socioeconomic characteristics of the general military population, including military families, with information on Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) warfighters. These data are intended to provide more in-depth background on both the similarities and the differences between the TRICARE population and other managed–health-care populations.

In general, a high-school diploma or general equivalency diploma (GED) is required for enlistment in the military, and 98.4% and 93.7% of new active-duty enlistees and new Reserve enlistees, respectively, in FY 2007 had at least a high-school diploma or the equivalent. In contrast, 81.2% of the 18- to 24-year-old civilian population have met those educational standards. Of the enlisted force as a whole (Table B.1), 98.4% of active-duty enlisted service members have at least a high-school

diploma or GED compared with 93.8% in the reserve components and 84.5% of the civilian population over 25 years old (DOD, 2007).

The vast majority of commissioned and warrant officers—87.3% on active duty and 85.6% in the reserve components—hold at least a college degree (Table B.1). In general, a college degree is required for appointment as a commissioned, but not warrant, officer. Among all enlisted members, 4.4% on active duty and 7.4% in the reserve components are at least college graduates. In the combined officer corps and enlisted corps, 17.8% of the active-duty force and 19.1% of the reserve force have at least a bachelor’s degree. In comparison, 27.5% of the civilian population over 25 years old have at least graduated from college (DOD, 2007).

In both the active and reserve components, minority groups (self-reported as African American or black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian or other Pacific islander, multiracial, or other or unknown) make up greater proportions of the enlisted ranks than of the officer corps. Put another way, of all minority-group members of the reserve components, 10.4% are officers and 89.6% enlisted; similarly, of active-duty minority-group members, 10.7% are officers and 89.3% enlisted. In both cases, the proportion of minority-group members who are officers—16.2% on active duty and 14.9% in the reserve components—is lower than the overall proportion who are officers. Of women, 17.1% on active duty are officers, and 15.2% in the reserve components are officers (DOD, 2007). Breakdowns of the military population by race and ethnicity are shown in Table B.2.

In the overall population of people 17–64 years old, 42.6% are single (including divorced and widowed) (US Census Bureau, 2009). In comparison, 44.8% of active-duty service members and 51% of Reserves are single. Of active-duty service members, 43.1% have dependent children, defined as dependents under 23 years old who are enrolled as full-time students. As might be expected, older service members are more likely to have children than younger members. However, officers in the general or admiral ranks are less likely than officers ranking between major or lieutenant commander and colonel or captain to have dependent children. That is probably because the children of generals and admirals have already passed the age of 23 years. The same patterns are found in the reserve components, although the overall proportion of members who have children is 41.9%. In both active-duty and reserve-component families with children, the average number of children is 2. However, the age distribution of children differs between active and reserve components, as shown in Table B.3 (DOD, 2007). In the civilian population, the average number of children in families with children is 1.86 (US Census Bureau, 2008).

The largest proportion, 25.51%, of new active-duty enlistees come from communities that have median incomes of $42,040–51,127. Communities that have median incomes of $33,268–65,031 provide

70.09% of new active-duty enlistees (DOD Task Force on Mental Health, 2007). It is difficult to compare military pay with civilian pay directly because military compensation includes salary, tax breaks, housing benefits, and health care. However, for illustrative purposes, an Army sergeant (E-5) with 4 years of service who is married and has children could earn about $47,000, including benefits, per year. A first lieutenant (O-2) in the same situation could earn about $68,000 per year (US Army, 2008). In active-duty families, 42% of officers’ spouses are out of the workforce (neither employed nor seeking employment) compared with 31% of enlisted members’ spouses (DOD, 2007).

In summary, the active-duty military population is more likely to have graduated from high school but less likely to have graduated from college than the civilian population (Table B.1). Active-duty service members are about as likely to be single as the general population, whereas reservists are more likely to be single. Compensation in the military is competitive with civilian salaries. In both active-duty and Reserve families with children, the average number of children is 2, a little higher than in the general population, and more young children (0–5 years old) are found in active-duty families than in Reserve families (Table B.3).

As of October 2007, more than 1.6 million US service members had been deployed to Iraq and Afghanistan (Tanielian and Jaycox, 2008). Among the OIF and OEF service members, there has been a marked increase of women among the ranks: 15% on active duty, 24% in the

Army Reserves, and 13% in the National Guard (DOD, 2007). The increase in cultural and racial diversity indicates a need to be cognizant of “culturally responsive” clinical practice.

Demographic shifts in recent war zones have resulted in a stronger presence of women serving in combat zones, a higher rate of married reservists (49%), an increase in dual-career military couples, and higher proportions of women in the National Guard and the Reserves. More than half (57%) of active-duty service members have family responsibilities (a partner, children, or other dependents). Among Reserve and National Guard families, 49% are married, and 42% have children (DOD, 2007).

As of January 2, 2010, 5,297 troops had been killed in the OIF and OEF conflicts, 4,361 in the OIF theater and 936 in the OEF theater (DOD, 2010). Most (73%) of the fallen served in the Army. About half (51%) of those troops were under 25 years old. A total of 36,364 had been wounded in action as the result of hostile activity as of January 2, 2010: 31,616 in the OIF theater and 4,748 in the OEF theater. Over 65% of these injuries were the result of explosive devices. Data on psychological injuries suffered during combat are not available.

In a RAND monograph, Tanielian and Jaycox (2008) estimated that 320,000 service members experienced a probable traumatic brain injury during deployment. However, in their sample of 1,965 previously deployed persons, only 43% had been evaluated by a physician or specialist for possible brain injury. That low rate of access raises questions about barriers to service, about whether stigma influences help seeking, and about whether lack of preparedness among family members and providers prevents them from recognizing symptoms and concerns associated with brain injury. Many of those veterans will be treated in polytrauma centers that involve long-term rehabilitation, so clinicians who work with them and their family members need to understand the complexity of the physical, psychosocial, and mental health issues for everyone involved.

DOD (Department of Defense). 2007. Demographics 2007: Profile of the military community. http://cs.mhf.dod.mil/content/dav/mhf/QOL-Library/Project%20Documents/MilitaryHOMEFRONT/Reports/2007%20Demographics.pdf. (Accessed July 28, 2009).

DOD. 2010. Military casualty information. http://siadapp.dmdc.osd.mil/personnel/CASUALTY/castop.htm. (Accessed January 15, 2010).

DOD Task Force on Mental Health. 2007. An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board.

Tanielian T, Jaycox LH (Eds.). 2008. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation. http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf. (Accessed January 15, 2010).

US Census Bureau. 2008. Annual estimates of the population by sex, race, and Hispanic origin for the United States: April 1, 2000 to July 1, 2007 (nc-est2007-03). http://www.census.gov/compenia/statab/tables/09s0006.pdf. (Accessed July 31, 2009).

US Census Bureau. 2009. America’s families and living arrangements—Table A1, “Marital status of people 15 years and over, by age, sex, personal earnings, race, and Hispanic origin, 2008. http://www.census.gov/population/www/socdemo/hh-fam/cps2008.html. (Accessed July 28, 2009).