Assessment of Readjustment Needs of
Veterans, Service Members, and Their
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
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.
Advisers to the Nation on Science, Engineering, and Medicine
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.
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
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
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
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.
*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.
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.
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
|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|
|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|
|GAO||Government Accountability Office|
|GWOT||Global War on Terror|
|ICD||International Statistical Classification of Diseases|
|IOM||Institute of Medicine|