More than a decade of war in Iraq and Afghanistan has placed extraordinary demands and stressors on our service members and their families, and some service members have returned with psychological injuries or impairments that will have consequences for years to come. The increasing rates of mental health diagnoses among service members, the related emotional and psychological tolls on families, and the rising costs associated with mental health treatment all indicate that there is an urgent need to prevent or mitigate psychological health problems before they impair function and become chronic. Effective prevention has the potential to reduce the need for treatment and long-term management of mental health disorders and to reduce the enormous personal, social, and economic costs associated with these conditions. Both the Department of Defense (DOD) and the various military services have implemented programs and strategies designed to promote psychological health and resilience in an attempt to limit the degree to which combat exposure and the demands of service interfere with a service member’s quality of life, service duties, and transition back to work and home. In addition, in recent years DOD and various communities have increased support for military families by offering familyfocused programs aimed at behavioral health, quality of life, and other support services. More can be done, however. DOD’s increased focus on developing and implementing effective prevention strategies is necessary not only for the benefit of service members who served in the recent conflicts and their families, but also for preparing for possible future conflicts.
In March 2013 the Institute of Medicine (IOM) released Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. The IOM report, which was congressionally mandated under Section 1661 of the National Defense Authorization Act for fiscal year 2008, documents the findings and recommendations of an IOM committee that studied the physical and mental health and other readjustment needs of members and former members of the armed forces who were deployed in Operation Enduring Freedom in Afghanistan or Operation Iraqi Freedom in Iraq; the report also examines the related needs of the service members’ families and their communities. The report covered a variety of topics, including health outcomes, mental health treatment, access to care, family issues, community effects, and economic impacts; however, it did not examine the prevention of psychological health disorders. DOD requested that the IOM conduct this followon study to assess these important aspects of health for service members and their families.
Charge to the Committee
DOD requested that the IOM convene an ad hoc committee to conduct a systematic review and critique of reintegration programs and prevention strategies for behavioral and mental health outcomes for service members and their families (i.e., posttraumatic stress disorder, or PTSD; depression; recovery support; and the prevention of substance abuse, suicide, and interpersonal violence). Additionally, DOD tasked the committee with identifying various models for measuring performance of prevention programs. The committee was directed to hold an information-sharing meeting that convened stakeholders and subject-matter experts associated with program evaluation and prevention efforts. Specifically, the IOM committee’s tasks were as follows:
• Conduct a systematic review and critique of reintegration programs and prevention strategies for PTSD, depression, recovery support, and prevention of substance abuse, suicide, and interpersonal violence.
• Identify various performance measures (e.g., cost, quality, outcomes, process, access, patient satisfaction, and documentation) of prevention programs.
• Identify the best metrics (i.e., performance measures) for evaluating resilience programs and prevention strategies using the National Quality Forum (NQF) framework.
• Include an overview of the most recent conceptualization of how prevention overlaps with the psychological health outpatient clinical pathway for PTSD. In doing so, consider the utility of the Porter model.
• Conduct an information-sharing meeting with stakeholders and subject-matter experts associated with program evaluations and prevention efforts.
The committee that the IOM appointed to respond to the charge was composed of 13 experts with expertise in epidemiology, psychology, psychiatry, clinical medicine, prevention, evaluation, PTSD, depression, recovery support, substance use disorders, suicide, and interpersonal violence.
Committee’s Approach to Its Charge
The committee held 4 meetings over 7 months, including information-gathering sessions that were open to the public and which involved presentations from the sponsor, subject-matter experts from DOD, other government agencies, and military advocacy organizations.
To gather information the committee identified and reviewed relevant studies in the peer-reviewed literature; reviewed applicable government reports, Internet resources, and congressional testimony; reviewed recent IOM reports on military health, psychological health, and prevention; and heard presentations from subject-matter experts. The committee also conducted extensive searches of the peer-reviewed and gray literature (including government and private-sector reports and Internet-only resources) and reviewed existing performance measures from three sources that are the products of national efforts to organize, manage, and promulgate the use of performance measures: the National Behavioral Health Quality Framework, developed by the Substance Abuse and Mental Health Services Administration; the NQF Quality Positioning System; and the National Quality Measures Clearinghouse, maintained by the Agency for Healthcare Research and Quality.
Prevention strategies designed to reduce the onset and severity of PTSD, depression, substance abuse, suicide, and interpersonal violence and to enhance responses to stress and trauma exposure as well as to promote reintegration with minimal challenges have the ultimate goal of creating good psychological health among military personnel and their families. Good psychological health is not simply the absence of diagnosable psychological health problems, although maintaining a state of good psychological health is likely to help protect against the development of many such problems. The committee holds the view that prevention should address both risk reduction and health promotion. Risk reduction targets specific outcomes or risk factors and health promotion focuses on increasing levels of health rather than preventing any particular disease. Prevention efforts aligned with health promotion emphasize fostering well-being with a goal of helping individuals lead healthy, thriving lives. In this view, the target of prevention programs is not only to prevent psychological health problems but also to promote positive psychological health, defined as a state of well-being in which persons can realize their abilities, cope with life’s stresses, and work regularly and productively.
Prevention is a set of strategies, complementary to the role of treatment, aimed at achieving a state of good psychological health, particularly in the context of population mental health. The committee adopted a conceptual approach that emphasizes prevention as part of a continuum, along with treatment and rehabilitation interventions, and uses the term “prevention” for interventions that occur before the onset of a full clinical disorder. For individuals with fullblown disorders, treatment should include prevention elements to lower the likelihood of relapse as well as associated negative outcomes. Universal prevention strategies are offered to the entire population, with the goal of the intervention being to reduce the probability of the undesired outcome. Selective prevention strategies are targeted to subpopulations identified as being at elevated risk for a disorder, for example, those being deployed to a war zone. Indicated prevention strategies are those targeted to individuals who have been identified as having increased vulnerability or risk for a disorder based on individual screening (but who are not currently symptomatic).
Being deployed to a war zone can result in numerous adverse psychological health conditions. It is well documented in the literature that there are high rates of psychological disorders among military personnel serving in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq as well as among the service members’ families. Between 2001 and 2011 the percentage of active-duty service members diagnosed with a psychological condition increased by approximately 62 percent. In 2011 there was a total of 963,283 service members and former service members who had been diagnosed with at least 1 psychological disorder during their period of service. Nearly 49 percent of these service members had been diagnosed with multiple psychological disorders. Between 2000 and 2011 diagnoses of adjustment disorders, depression, and anxiety disorders (excluding PTSD) made up, respectively, 26 percent, 17 percent, and 10 percent of all psychological disorder diagnoses. PTSD represented approximately 6 percent of psychological disorders diagnoses, and abuse and dependence on alcohol and other substances accounted for 17 percent of diagnoses during this time period.
For service members’ families, the degree of hardship and negative consequences rises with the amount of the service members’ exposure to traumatic or life-altering experiences. Adult and child members of the families of service members who experience wartime deployments have been found to be at increased risk for symptoms of psychological disorders and to be more likely to use mental health services.
In an effort to provide early recognition and early intervention that meet the psychological health needs of service members and their families, DOD currently screens for many of these conditions at numerous points during the military life cycle, and it is implementing structural interventions that support the improved integration of military line personnel, non-medical caregivers, and clinicians, such as RESPECT–Mil (Re-Engineering Systems of Primary Care Treatment in the Military), embedded mental health providers, and the Patient-Centered Medical Home. The committee’s review of risk and protective factors in military and family populations suggests that prevention strategies are needed at multiple levels—individual, interpersonal, institutional, community, and societal—in order to address the influence that these factors have on psychological health.
DOD has implemented numerous resilience and prevention programs that address various aspects of psychological health. As DOD advances its efforts to evaluate and improve psychological health programming for service members and their families, it faces a number of challenges, such as insufficient empirical evidence for many of the prevention programs it has implemented, the fact that there has been no systematic use of national performance measures to assess current DOD screening programs, and the lack of a systematic process to select validated measures for use in judging the performance of the structure, process, and outcomes of all prevention initiatives for enhancing psychological health. The measurement of performance is not as advanced in psychological health as it is in other types of care. Nonetheless, DOD can focus its resources on creating a systematic approach to the measurement of structure, process, and outcomes with reporting to an effective oversight structure aimed at monitoring, selecting, and improving the quality of prevention initiatives for service members and their families.
The committee’s findings led to recommendations for improving programs aimed at strengthening resilience and reintegration, assessing psychological health risks, using evidencebased interventions, and implementing measurement and evaluation strategies.
EFFECTIVENESS AND COST-EFFECTIVENESS
Resilience, prevention, and reintegration interventions should be based on wellestablished theoretical frameworks. Assessments of DOD programs conducted by this committee and others show that a majority of DOD resilience, prevention, and reintegration programs are not consistently based on evidence and that programs are evaluated infrequently or inadequately. For example, on the basis of internal research data that show only very small effect sizes, DOD
concluded that Comprehensive Soldier Fitness, a broadly implemented program intended to foster resilience, is effective—despite external evaluations that dispute that conclusion. Among the small number of DOD-sponsored reintegration programs that exist, none appears to be based on scientific evidence. The committee was unable to identify any DOD evidence-based programs addressing the prevention of domestic abuse. More recently, the services have implemented a number of prevention interventions to address military sexual assault, yet a DOD review found that critical evaluation components needed to measure their effectiveness are missing.
In addition, there are many DOD prevention interventions that rely on adaptations from civilian prevention programs but have not been tested with military populations, particularly in the case of programs that are family-focused or target substance misuse. The committee also found that environmental strategies with strong evidence of effectiveness are underutilized, such as restricting access to lethal means such as personal firearms to prevent suicide or homicide in domestic violence cases or placing restrictions on the sale of alcohol to reduce substance misuse. In place of these proven approaches, the committee typically found interventions such as campaigns, Internet tools, or in-person events with no evidence for their effectiveness at preventing the targeted problem. Finally, the committee found limited ongoing evaluation to inform program areas lacking evidence, and a clear need for longitudinal follow-up assessment to determine the impact of resilience, prevention, and early intervention efforts.
To the degree that these shortcomings exist in DOD’s use of evidence-based practices, they can degrade the department’s ability to maintain or improve the psychological health and well-being of service members and their families and can lead to the inefficient use or waste of scarce resources that could otherwise be used to address the enormous task of preventing psychological health problems. The committee concludes that by targeting resources to develop the evidence base and facilitate the process of evidence dissemination and implementation, DOD can optimize the effectiveness and cost-effectiveness of interventions to prevent psychological health problems.
Recommendation 1: The committee recommends that the Department of Defense (DOD) employ only evidence-based resilience, prevention, and reintegration programs and policies and that it eliminate non-evidence-based programming. Where programming needs exist and the evidence base is insufficient, DOD should use rigorous methods to develop, test, monitor, and evaluate new programming.
RISK IDENTIFICATION AND INTERVENTION
DOD implements systematic screening processes to identify service members at risk for a specific psychological health problem annually and at various points in the military life cycle—at accession (entrance into the military), pre-deployment, and post-deployment. The committee found that DOD is administering some screening instruments that are not evidence-based and have not been validated. Examples include instruments used during accession to determine the acceptability of applicants for military service, specifically, questions about recent depression and the “Omaha 5” instrument that examines a range of psychological health issues. In addition, the committee found that unnecessary variability exists among the types of screening instruments that are administered at different points in the military life cycle. For example, the questions about depression and suicidal ideation administered during the accession process are not the
same as those included in the post-deployment health assessments. The use of non-validated screening instruments at accession is a concern because studies show that enlistees may enter the military with elevated rates of psychological health disorders.
In addition, the committee found that although DOD conducts systematic psychological health screening of service members at various phases in the military life cycle as well as in primary care clinics, it does not have a routine health screening program targeting service members who are about to separate from the military. With appropriate processes for referral and for the coordination of care between the military health system and non-military health providers, including the Veterans Health Administration, screening at separation may help to improve reintegration back into civilian life. This would benefit former members of the military, their families, and the communities in which they reside.
The committee found no systematic psychological health screening for military spouses and children. The committee acknowledges DOD’s recent policy to expand screening requirements in primary care settings located within military treatment facilities; however, the policy will have a limited effect on military spouses and children because they predominately receive care from the network of civilian providers and facilities in the purchased care system.
Furthermore, there is a lack of information on the extent to which there is appropriate and timely follow-up with targeted interventions to individuals and families with at-risk psychological profiles. In order to improve readiness and transitions to civilian life, it will be imperative to use findings from screenings and risk assessments throughout the military life cycle to target interventions. Overall, the committee concludes that there is a need for DOD to improve approaches for identifying and intervening with service members and members of service members’ families who are at risk of developing psychological health problems or who have a diagnosable condition.
Recommendation 2: The committee recommends that the Department of Defense consistently use validated psychological screening instruments appropriate to the type of screening and conduct systematic targeted prevention annually and across the military life cycle (from accession to pre-deployment, deployment, postdeployment, reintegration, and separation) for service members and their families.
MEASUREMENT AND EVALUATION
Preventive intervention programs should be rigorously designed, and the programs and their components should be evaluated extensively. This should occur as the program is being developed, while it is being conducted, and after it has been completed. Dedicated resources (e.g., funding, staffing, and logistical support) for data analysis and evaluation are essential to ongoing performance monitoring for quality improvement and accountability. The committee concluded that there is no generally accepted comprehensive set of measures to assess the structure, process, and outcomes in resilience, prevention, and reintegration programming. The committee’s review of existing measures in national quality measure sets found few measures relevant to psychological health, and those that do exist are primarily clinically focused screening measures that do not sufficiently address all of the domains relevant to resilience, prevention, and reintegration. Moreover, the committee found that DOD lacks a strategy, a framework, and a range of measures for monitoring performance that ultimately can be used to
assess resilience, reintegration, and good psychological health to determine program effectiveness.
Recommendation 3: The committee recommends that, when appropriate, the Department of Defense (DOD) employ existing evidence-based measures using the systematic approach identified in this report. When appropriate measures are not available, DOD should develop and test measures to assess the structure, process, and outcomes of prevention interventions across the phases of the military life cycle.
The demands placed on military families call for support in the areas of relationship building, family and individual function, and reduction of risk of psychological and physical health problems. Policy and management responsibilities for family-focused programs span the DOD enterprise. Each military service and the Office of the Secretary of Defense administer dozens of family-focused prevention programs. The committee’s review of the literature revealed that, despite existing programming, many of the risks and vulnerabilities military families face are associated with family violence, substance abuse, stress reaction, stigma, and depression. The committee’s review of programs in this study and its review of recent comprehensive assessments of military family programs share the common finding that there are gaps in the evidence supporting the effectiveness of interventions for military families. The committee recognizes there are initiatives in place to build the research base in family-focused programs, but believes a more coordinated, comprehensive and systematic approach is needed to support the development and implementation of evidence-based prevention programming for military spouses, partners, and children that address risk and vulnerabilities specific to particular points in the military life cycle.
Recommendation 4: The committee recommends that the Department of Defense implement comprehensive universal, selective, and indicated evidence-based prevention programming targeting psychological health in military families, spouses, partners, and children. The targeted risks and vulnerabilities should include family violence, substance abuse, stress reaction, stigma, and depression.
COMMUNITY CHARACTERISTICS AND INTERVENTIONS
The communities in which service members and their families live or to which they return can shape the risk and protective factors that affect individual behaviors and psychological health outcomes. For example, in the civilian literature, there is ample evidence that both price and availability of alcohol in communities impacts the rates of the negative consequences of its use. In its review of the literature the committee found a dearth of studies examining how community factors impact readiness and reintegration among military service members and their families. The committee believes research is this area would help to inform the development of effective community-level prevention interventions for service members and their families.
Recommendation 5: The committee recommends that the Department of Defense (DOD) use existing evidence-based community-level prevention interventions and policies to address the psychological health of military members and their families. Where sufficient evidence does not exist, DOD should support research on the effects of communities and social environments on service members and their families.
The committee believes that, together, the above five recommendations will improve DOD’s ability to manage a complex set of issues in military psychological health programming. In addition, the committee believes that the recommendations would best serve DOD if they are considered in the context of changes to the current organizational infrastructure for program development, implementation, evaluation, and tracking. Although an array of programs exist for resilience, reintegration, and psychological health for service members and their families, the committee’s literature and program review revealed that DOD’s current infrastructure does not support optimal programming.
Recommendations about specific changes to the current organization or infrastructure are beyond the scope of this committee’s charge; however, the committee believes that the execution of its recommendations relies on DOD’s consideration of appropriate organizational restructuring to achieve these goals. Areas important to examine include those associated with centralizing DOD-wide and service-specific programming, accountability and oversight, budget, and setting overall policies and guidelines for the development, implementation, evaluation, and tracking of resilience, reintegration, prevention, and treatment programs for service members and their families. Processes that require attention include (1) continuing efforts to systematically identify and track program gaps by building on the comprehensive reviews conducted by this committee and others; (2) coordinating programming across the military services; (3) defining what constitutes a program and the type and level of evidence required before full rollout; (4) establishing evaluation requirements for new and existing programs that are aligned with their stated aims; (5) implementing a mechanism for sharing evidence and best practices across program areas and services; and (6) creating procedures for discontinuing ineffective or duplicative programs and for implementing programs demonstrated to be highly effective, costeffective, and culturally diverse. The reporting of these functions for transparency and accountability purposes is a critical component to ongoing program quality improvement.