As of December 2012, Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in the deployment of about 2.2 million troops; there have been 2,222 US fatalities in OEF and Operation New Dawn (OND)2 and 4,422 in OIF. The numbers of wounded US troops exceed 16,000 in Afghanistan and 32,000 in Iraq. In addition to deaths and morbidity, the operations have unforeseen consequences that are yet to be fully understood.
In contrast with previous conflicts, the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments. Numerous reports in the popular press have made the public aware of issues that have pointed to the difficulty of military personnel in readjusting after returning from Iraq and Afghanistan. Many of those who have served in OEF and OIF readjust with few difficulties, but others have problems in readjusting to home, reconnecting with family members, finding employment, and returning to school.
In response to the return of large numbers of veterans from Iraq and Afghanistan with physical-health and mental-health problems and to the growing readjustment needs of active-duty service members, veterans, and their family members, Congress included Section 1661 of the National Defense Authorization Act for fiscal year 2008. That section required the secretary of defense, in consultation with the secretary of veterans affairs, to enter into an agreement with the National Academies for a study of the physical-health, mental-health, and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF, their
1 The text in this appendix is drawn from the Summary of the Institute of Medicine report Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Service Members and Their Families (Washington, DC: The National Academies Press, 2013).
2 Operation Enduring Freedom (OEF) is the name for the war in Afghanistan. Operation Iraqi Freedom (OIF) is the name of the conflict in Iraq that began on March 20, 2003, and ended on December 15, 2011. On September 1, 2010, Operation New Dawn (OND) became the new name of OIF. The committee’s focus has been on OEF and OIF, inasmuch as no or few data on the OND deployed were available.
families, and their communities as a result of such deployment. The study was assigned to the Institute of Medicine (IOM).
The study consisted of two phases. The Phase 1 task was to conduct a preliminary assessment. The Phase 2 task was to provide a comprehensive assessment of the physical, psychologic, social, and economic effects of deployment on and identification of gaps in care for members and former members, their families, and their communities. The Phase 1 report was completed in March 2010 and delivered to the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the relevant committees of the House of Representatives and the Senate. The secretaries of DOD and VA responded to the Phase 1 report in September 2010. The present report fulfills the requirement for Phase 2.
COMMITTEE’S APPROACH TO ITS TASK
IOM appointed a committee of 29 experts to carry out the Phase 2 study. The committee approached its task by identifying and reviewing data in the peer-reviewed literature; reviewing government reports and testimony before Congress; reviewing recent IOM reports on posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and physiologic, psychologic, and psychosocial effects of deployment-related stress; obtaining information directly from DOD and VA; and inviting DOD and VA researchers and officials to present data. The committee also sought input from community leaders to determine effects at the community level; it conducted data analyses and examined data in administrative datasets. Those data-gathering efforts provided the committee with a broad overview of possible readjustment needs and possible solutions related to the effects of deployment in OEF and OIF. Chapter 2 describes in detail the committee’s approach to its task.
The readjustment needs of service members, veterans, and families that have experienced deployment to OEF or OIF encompass a complex set of health, economic, and social issues. Below are the committee’s key findings, which to a large extent are the focus of its recommendations.
• Many veterans return from deployment relatively unscathed by their experience, but others return from deployment with a multitude of complex health outcomes that present life-long challenges and hinder readjustment.
• Not all veterans who need treatment receive it despite the offering of evidence-based treatments by the VA and DOD health systems, because systemwide challenges exist.
• Military families often endure the adverse consequences of deployments, for example, health effects, family violence, and economic burdens.
• Numerous programs exist to respond to the needs of returning OEF and OIF active-duty personnel, veterans, and family members, but there is little evidence regarding their effectiveness.
• Unemployment and underemployment are acute problems for military veterans.
• Published data on the effects of deployment on military communities are sparse.
• DOD, VA, and other federal agencies have data that can answer many of the questions posed in the legislation; however, numerous barriers must be overcome to facilitate sharing and linking of data.
The federal government, in particular DOD and VA, is actively seeking to understand the scope of readjustment challenges, implement appropriate policies, and provide programs and services. In many cases, however, the response does not match the magnitude of the problems, and many readjustment needs are unmet or unknown. The urgency of addressing those issues is heightened by the sheer number of people affected, the rapid drawdown of personnel from Afghanistan and Iraq, and the long-term effects that many of the issues might have not only on military personnel and veterans and their families but on the country as a whole. Previous wars have demonstrated that veterans’ needs peak several decades after the war in which they served, and that highlights the need for managing current problems and planning future resources.
To inform its work during the second phase of its study, the committee read the literature, collected data and attempted data analyses, oversaw ethnographic research, and tabulated current research in the OEF and OIF populations. The committee’s recommendations are presented below.
The literature on the outcomes of military deployment has grown dramatically over the last two decades. Although discrepant findings do emerge, there is a clear consensus in the literature that the stressors of deployment, from exposure to combat to multiple deployments away from home and family, can lead to a number of adverse conditions. The committee concentrated on deployment-related outcomes—such as TBI, PTSD, depression, substance use, and suicidal ideation—but the list could be expanded to many additional psychiatric conditions and a host of physical conditions. The data on short-term outcomes (outcomes in 6 months or less) is extensive, but data on long-term outcomes (over years) is less extensive and both can be challenged on methodologic grounds. To capture the true long-term outcomes of deployment to war zones and plan services to address them, more data will be essential.
The committee recommends that the Department of Defense and the Department of Veterans Affairs sponsor longitudinal studies to answer many of the questions regarding long-term effects of traumatic brain injury, posttraumatic stress disorder, and other mental-health disorders. Such studies should strive to improve the validity of exposure measurements, identification and use of biomarkers, and recruitment and retention of subjects. Attention should be paid to whether the outcomes of traumatic brain injuries depend on the severity and number of such injuries, on the presence of comorbid conditions, and on sex and ethnicity.
Current studies might be the most appropriate platform for developing a strategy for long-term followup, such as the Millennium Cohort Study and the Longitudinal Health Study of Gulf War Era Veterans. Those studies can be augmented with supplementary samples of OEF, OIF, and OND veterans. Other factors that should define such studies include the ability to collect biologic specimens, oversampling of OEF, OIF, and OND female and minority-group populations, and planning for add-on studies to address new needs as they are identified.
Many health consequences of service in OEF, OIF, and OND are related to the inherently dangerous nature of the wartime environment or resulting trauma. However, one major exposure, military sexual trauma (MST), is unrelated to war but rather is due to noncombat violent assault. Studies show that MST has been occurring at high rates in the US military, including during OEF, OIF, and OND. Research demonstrates that MST is associated with poor readjustment and adverse mental-health and physical outcomes. The burden of physical- and mental-health consequences for the victims and their family members is high. Increased efforts by DOD are necessary, and a zero-tolerance approach should be implemented.
The committee recommends that the Department of Defense develop policies to eliminate military sexual trauma as research demonstrates that it is associated with poor readjustment and mental-health and physical-health outcomes. The committee further recommends that the department reinforce existing policies on military sexual trauma by adding specific mandatory evaluation criteria regarding how well military leaders address the issue, for example, in the formal performance-appraisal and promotion systems.
The breadth and depth of the challenges faced by military service members and veterans who served in Iraq and Afghanistan result from the complex interaction of issues that must be addressed by primary prevention, diagnostics, treatment, rehabilitation, education and outreach, and community support programs if readjustment after combat service is to be successful.
Screening, assessment, and treatment approaches for brain injuries and psychologic health problems are not always implemented between and within DOD and VA in a consistent manner or aligned with the evidence base. DOD and VA use different thresholds for some of the same mental-health screening and assessment instruments, such as the Primary-Care PTSD screen and the PTSD Checklist for PTSD and the Patient Health Questionnaire for depression. Parts of VA and DOD clinical guidance lack recommendations for a specific assessment instrument and leave the selection of instrument to the clinician, for example, for suicide-risk assessments and TBI neurocognitive assessments.
The committee identified topics on which VA and DOD policies are out of step with the evidence base. There is a lack of clear scientific evidence supporting the effectiveness of the neurocognitive assessment tool (Automated Neuropsychological Assessment Metrics) used by DOD to assess cognitive function after a head injury. With respect to suicide prevention, DOD policy prohibits restricting access to privately owned weapons for those who might be at risk for suicide, but research shows that restricting access to lethal means prevents suicides. VA has included Acceptance and Commitment Therapy for depression in its national rollout of evidenced-based treatments; however, there is not sufficient evidence to support its use as a firstline intervention. Moreover, the limited data that are available suggest that patients in need of evidence-based care might not be receiving it. The committee has serious concerns about inadequate and untimely clinical followup and low rates of delivery of evidence-based treatments, particularly psychotherapies to treat PTSD and depression and approved pharmacotherapies for substance use disorder.
The committee recommends that the Department of Defense and the Department of Veterans Affairs select instruments and their thresholds for mental health screening and assessment in a standardized way on the basis of the best available evidence. The committee also recommends that the two departments ensure that treatment offerings are aligned with the evidence base, particularly before national rollouts, and that all patients consistently receive first-line treatments as indicated.
Unwarranted variability in clinical practices and deviations from the evidence base present threats to high-quality patient care. Such variability also hampers opportunities to make research comparisons that can inform and improve the effectiveness of screening, assessment, and treatment practices. The committee notes that the emphasis on promoting evidence-based practices should not discourage the use of new or experimental interventions where there is reason to believe that they might lead to better outcomes than standard interventions.
In many ways, DOD and VA clinicians are at the forefront of providing evidence-based care for service members and veterans who have brain injuries and psychologic-health problems. But there are opportunities to improve processes of training and evaluating clinicians. DOD does not have a standardized process for assessing clinicians’ competence to administer the Military Acute Concussion Evaluation for TBI. VA is implementing a robust clinician-training program to disseminate evidence-based psychotherapies, but the program appears to lack periodic clinician assessments beyond the 6-month training period to ensure that continued treatment fidelity is maintained. Current approaches for training clinicians on the management of comorbid conditions (by disseminating clinician resources, for example) are not adequate.
The committee recommends that the Department of Defense and the Department of Veterans Affairs incorporate continuing supervision and education into programs that train clinicians in the use of selected assessment instruments and evidence-based treatments. Once clinicians are trained, the two departments should systematically and periodically evaluate them to assess the degree to which therapeutic interventions are accurately implemented according to a manual, protocol, or model as supported by evidence. The committee also recommends that the two departments place greater focus on coordinated, interdisciplinary care to ensure optimal treatment for service members and veterans.
The committee determined that there are few data on whether screening, assessment, and treatment interventions in DOD and VA are being implemented according to clinical guidelines and VA and DOD policy. Minimal data are readily available on the numbers of people who have been screened and the extent to which followup is appropriate and timely for those who screen positive. There is a dearth of data on which treatments patients receive and whether the treatments were appropriate, timely, and delivered at the recommended intensity level (for example, individual vs group format and frequency and duration of sessions).
The committee recommends that the Department of Defense and the Department of Veterans Affairs conduct systematic assessments to determine whether screening and treatment interventions are being implemented according to clinical guidelines and department policy. Data systems should be developed to assess treatment outcomes, variations among treatment facilities, and barriers to the use of evidence-based treatment.
The committee found that DOD has many programs and policies to support families. However, DOD policies, programs, and practices typically do not take into consideration the full spectrum of military families. By focusing almost exclusively on traditional families (married heterosexual spouses and their children), DOD is missing critical opportunities to support the readjustment needs of many service members’ nontraditional families. To be able to support all families, DOD will need data on the full constellation of service members’ family.
The committee recommends that the Department of Defense ensure that policies, programs, and practices aim to support and strengthen all military families, including nontraditional ones.
Healthy families help service members to do their jobs effectively and readjust after deployment. The demands placed on military family members call for support in the areas of relationship building, family and individual function, and reduction of risk of psychologic and physical-health problems. The committee found that little information is available on the potential effectiveness of broad-based, universal prevention efforts aimed at military children and their families. In addition, most treatment interventions for family members have been developed and tested in civilian communities and lack evidence of their effectiveness for military families. The committee concludes that military families would benefit from increased efforts to identify, develop, and test new prevention and treatment interventions targeted toward military families, including interventions directed at children and adolescents.
The committee recommends that the Department of Defense use evidence-based primary prevention programs and treatments that have been specifically evaluated in service members and their families and that are focused on preventing and treating mental-health and relationship problems.
The committee concludes that there are substantial gaps in knowledge about the effects of deployment on military families that hinder DOD’s ability to meet the needs of military service members and their families effectively. The committee found that—although some important large-scale, well-designed studies are under way—much of the research heretofore has been methodologically flawed, suffering, for example, from the use of small convenience samples, use of cross-sectional designs, and the like. The committee concludes that well-designed studies that use rigorous and diverse methods (both qualitative and quantitative) are needed to increase understanding of the challenges faced by military service members and their families.
The committee recommends that the Department of Defense and other relevant federal agencies fund methodologically rigorous research on the social,
psychologic, and economic effects of deployments on families, including nontraditional families.
Studies of families of service members deployed to OEF and OIF have documented a rise in domestic violence (typically including abuse of spouses or neglect of children). In the FY 2000 National Defense Authorization Act (PL 106-65, Section 591), Congress directed the secretary of defense to establish a Defense Task Force on Domestic Violence to make recommendations for reducing the prevalence of domestic violence in military families. The task force submitted a report in 2003 that identified multiple shortcomings in the current systems and recommended many improvements. The Government Accountability Office, in 2006 and 2010, issued reports concerning progress in implementing the nearly 200 recommendations made by the task force. Both reports described progress on some recommendations but little on others, including a recommendation for reliable documentation of violent events.
The committee recommends that the Department of Defense place high priority on reducing domestic violence because it degrades force readiness and the well-being of military family members.
There has been too little research on community effects of deployments to OEF and OIF. To supplement the published research, the committee completed ethnographic assessments in six communities that are near large military installations or that have recently deployed National Guard populations. Those efforts provided some insight, but the lack of communitywide assessments of the effects of OEF and OIF deployments on communities made it difficult to respond to this aspect of the committee’s charge.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other relevant federal agencies fund research on the effects of Operation Enduring Freedom and Operation Iraqi Freedom deployments on communities. Such research should include current indicators of community wellbeing, such as measures of economic performance, availability of social and support services, law-enforcement activity, and school and educational functioning.
Relevant data are available, but data linkages are needed to allow specific analyses that can more clearly illuminate opportunities to mitigate potential adverse community consequences after service members deploy, return, and separate.
Problems of unemployment and underemployment, which are broadly felt by the US civilian population today, appear to be more acute for veterans of the post-9/11 era, particularly young veterans. In 2011, the unemployment rate among all post-9/11 veterans 18 years old and older was more than one-third higher than that among equivalent nonveterans—12.1% compared with 8.7%. Among veterans 18–24 years old, the rate was almost twice as high—30.2% compared with 16.1%. The sources of those disparities remain unclear and could include skills mismatch, impeded ability to maintain or obtain employment because of physical- or mental-
health trauma, stigma or discrimination, or some combination of those factors or other elements. Successful readjustment depends on reentry into the civilian workforce, and the available evidence suggests that this is an important gap for policy to address. The committee found that the literature assessing the effectiveness of DOD’s and VA’s transition-assistance programs is relatively thin, even though reentry into the labor force is one of the most important readjustment challenges. One study suggests that recent expansions of hiring tax credits might have been effective in raising rates of employment of older veterans who have disabilities. But OEF, OIF, and OND veterans did not appear to benefit from the expansions.
The committee recommends that the Department of Defense and the Department of Veterans Affairs evaluate the effectiveness of transition-assistance programs to ensure that they are effective in reducing unemployment among returning veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.
Evaluation of the effectiveness of transition-assistance programs, with research that examines employment patterns after separation from the military over time, will provide data to ensure that scarce resources can be allocated to effective programs. Further study might focus on whether employment tax credits are a cost-effective means of expanding employment for Operation Enduring Freedom and Operation Iraqi Freedom veterans and whether programs to counsel and prepare service members for long-term postservice careers are effectively implemented.
The Post-9/11 GI Bill is one of the largest expansions of educational subsidies to veterans and their families on record, but its effectiveness is difficult to gauge. The committee is aware of no studies that have explicitly evaluated the effects of deployment to OEF and OIF on the use of the Post-9/11 GI Bill or the effects of the Post-9/11 GI Bill.
The committee recommends a comprehensive evaluation of the effects of the Post-9/11 GI Bill on the educational attainment of veterans and eligible family members.
The committee views the current evidence on the costs of caring for injured veterans as an overwhelming challenge. There is a need to assess the costs of caring for injured veterans systematically and publicly. The Congressional Budget Office publicly assesses short-term and medium-term costs, and, as the VA stated in response to the committee’s Phase 1 report, it already produces some forecasts of health and disability spending. But the committee continues to believe that long-term planning for veterans’ care requires public long-term cost forecasts in the same way that Social Security and Medicare require them, and these forecasts should take a similar form to be internally and externally useful.
The committee reiterates its call for comprehensive long-term forecasts of the costs of the Veterans Health Administration’s medical care and the Veterans Benefits Administration’s disability benefits associated with combat deployments; these forecasts should be conducted annually and should be released publicly by the Department of Veterans Affairs and confirmed by an independent external authority.
ACCESS AND BARRIERS TO CARE
Transitioning from the DOD health care system to the VA health care system presents challenges for OEF and OIF service men and women. There are numerous difficulties in navigating services because of the complexities of both systems. Although DOD and VA are making administrative changes to alleviate some of the problems, information sharing between the two agencies remains a problem.
The committee recommends improved coordination of care and services between the Department of Defense and the Department of Veterans Affairs medical treatment facilities, including the completion of an interoperable or single combined electronic health record for all care that begins with entry into military service and continues throughout care in the Department of Veterans Affairs system after transition.
Stigma is still a problem for military personnel in care or seeking care for mental-health or substance-abuse problems. Active-duty military fear that visits to a mental-health provider will jeopardize their careers because of the military’s long-standing policy of reporting mentalhealth and substance-abuse problems to the chain of command. Mixed messages about seeking treatment and concerns about health-information privacy remain disincentives to seeking care.
The committee recommends that the Department of Defense continue to promote an environment that reduces stigma and encourages treatment for mental-health and substance-use disorders. The committee recommends that the department undertake a systematic review of its policies regarding mental-health and substance-abuse treatment with regard to issues of confidentiality and the relation between treatment-seeking and military advancement. The committee recommends that the department regularly issue reports describing actions taken with regard to its policies and procedures to determine progress in this area.
Excessive wait time is a complaint often expressed by both active-duty and veteran service members. Long wait times can compromise health because of delayed use and decreased patient satisfaction. In addition, adverse long-term outcomes, such as death and preventable hospitalizations, are more common for veterans who seek care at facilities that have longer wait times than for veterans at facilities that have shorter wait times.
Poor availability and misdistribution of mental-health specialists in many parts of the United States, especially in rural areas, present substantial barriers to OEF and OIF veterans’ access to mental-health care. For active-duty service members, inadequate participating provider networks present a challenge for accessing mental-health care.
The committee recommends that the Department of Defense and the Department of Veterans Affairs conduct a needs assessment to determine the numbers and types of providers needed to address the long-term health needs of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn activeduty service members and veterans. The Department of Defense and the Department of Veterans Affairs should determine the optimal team composition—for example, MDs, PhDs, RNs, master’s-trained professionals, and peer counselors—needed to ensure that providers function efficiently and perform at the upper level of their credentials and privileges.
There is evidence of cultural insensitivity to nonwhite service members, who might have different or more severe physical-health and mental-health problems from their white counterparts. For example, black personnel are less likely than white personnel to use mentalhealth services and quicker to drop out of treatment. Issues related to types of diagnoses and potential misdiagnoses have also been raised. Whether clinicians who have ethnic characteristics similar to those of their patients would alleviate those problems is unknown.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research to determine whether culturally sensitive clinicians and treatment approaches improve retention in care and improve clinical outcomes.
Women now constitute 14% of deployed forces in the US military, and an unprecedented number of female soldiers are deployed to combat areas. Although all service members are exposed to high levels of workplace stress, women in the military face some unique stressors, such as MST, which may affect their mental health and emotional well-being. Female veterans report a higher burden of medical illness and worse quality-of-life outcomes than do men who are exposed to the same levels of trauma. MST appears to be an important risk factor for the development of PTSD.
The committee recommends that the Department of Defense and the Department of Veterans Affairs consider ways to remove barriers and improve women’s access to and use of health care in their systems. The two departments should examine issues related to women’s circumstances and stressors—such as military workplace stress, sexual harassment and assault, posttraumatic stress disorder, and premilitary trauma—in an effort to reduce disparities and to provide health care that is sensitive to their needs and preferences.
PROPOSED DATA ANALYSES
There has been little quantitative characterization of the issues described in the legislation, but the committee identified a wide array of data and databases available in DOD, VA, and other federal agencies that could be used to address many of the questions posed by the legislation that motivated its work. On the basis of available data, the committee developed a comprehensive data-analysis plan. The committee notes that in addition to its recommendation for comprehensive data analyses, privacy experts will need to be involved with data owners before data are linked and made accessible to researchers. The committee believes that privacy
and confidentiality are essential alongside issues of coordination and synchronization of data sources.
The committee recommends that the Department of Defense and the Department of Veterans Affairs support comprehensive analyses of relevant data that reside in the two departments and other agencies of the federal government. Their databases should be linked and integrated so that they can be used effectively to address questions regarding readjustment that are not answered in the peerreviewed literature.
The committee’s preliminary work in this area has provided a clear rationale, justification, and roadmap for comprehensive data analyses. Comprehensive data analyses will require establishment of systematic, timely processes for using available government data and linking them in such a way as to improve the characterization of issues of interest. No databases or files fully integrate basic deployment and demographic data with data on health outcomes, treatment or transition-of-care files, data on access to care, records of employment before and after deployment, and data on other processes and outcomes. A comprehensive analytic database will have to be created and maintained.
The committee recommends that the secretary of defense and the secretary of veterans affairs establish an interagency work group to identify and examine the feasibility of linking data that exist in Executive Branch departments and agencies throughout the federal government. The work group should be tasked to explore issues related to coordination among agencies, for example, defining common goals, establishing common policies and procedures, creating mechanisms for data sharing, establishing records systems, and overcoming legal impediments and meeting legal requirements. The work group should provide the secretaries with options and recommendations for establishment of a sustainable program for longterm cooperation and data sharing to improve understanding of the outcomes of military service and readjustment after combat deployment.
The committee believes that many of the issues examined in this study can be addressed through analyses of data already maintained by numerous federal agencies. The committee tried to gain access to the data files so that it could begin such analyses, but it faced numerous obstacles in its attempts to access them. In light of those difficulties, the committee recommends the following actions to address many of the problems that it faced.
The committee recommends that clear procedures be developed for accessing data held by the Department of Defense, the Department of Veterans Affairs, and other federal agencies. The procedures should appear on each agency’s website with access to its data dictionaries. That would enable researchers and others wishing to access data to understand all the requirements before they begin their datagathering efforts and would provide information about the types of data that are available and how to access them.
The questions posed to the committee are complex and critical to the well-being of US veterans, their families, and the communities in which they live. A major finding of the
committee is that there is no way to provide data-based answers to those questions. All agencies that collect, store, and manage information relevant to veterans and their families should give high priority to coordination of those efforts throughout the federal statistical system so that informed decisions about veterans’ readjustment needs can be made in the near future.
The committee believes that such coordination will greatly enhance the ability of researchers and the government to link data held by multiple agencies to allow the types of analyses recommended above.