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 have returned with psychological injuries or impairments that will have consequences for years to come. The increasing rates of diagnoses of psychological disorders 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 psychological disorders and to reduce the enormous personal, social, and economic costs associated with these conditions. The Department of Defense (DOD), each military service, private groups, and states have implemented a number of programs and strategies to promote psychological health and resilience in an attempt to limit the degree to which combat exposure and 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 communities have increased support for military families by offering a catalog of family-focused programs aimed at behavioral health, quality of life, and other support services. However, as described in this report, more can be done. 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 in preparation for possible future conflicts. Although this report describes many of the challenges associated with improving prevention efforts in the military, improving prevention of psychological disorders is not a military-only problem. Many of the shortcomings described in this report reflect the overall inadequate response to prevention nationwide.
The high rates of psychological disorders among military personnel serving in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq and also among the service members’ families are well documented in the literature (Hoge et al., 2004; Hosek, 2011; IOM, 2013; Tanielian and Jaycox, 2008). Recently, the Congressional Research Service (CRS) reported that between 2001 and 2011, the rate of active-duty service members diagnosed with a psychological condition increased by approximately 62 percent, with the incidence rates of posttraumatic stress disorder (PTSD) and anxiety increasing 656 percent and 226 percent, respectively (Blakeley and Jansen, 2013). During their period of service, a total of 936,283 service members and former service members were diagnosed with at least 1 psychological disorder. Nearly 49 percent of these service members were 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 made up 17 percent over this time period. CRS concludes that the data, which come from the Armed Forces Surveillance Center, represent diagnoses and likely underestimate the actual incidence of psychological disorders because many cases are not identified. For example, these data do not include service members who may have a psychological problem but do not seek treatment and also exclude National Guard and reserve service members who seek medical treatment after they are deactivated.
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 (MacLean and Elder, 2007). Deployment to combat zones has been found to significantly predict a variety of negative outcomes, including marital conflict and intimate partner violence (Hoge et al., 2008). When service members display negative psychological symptoms, the likelihood of negative consequences for families rises substantially (de Burgh et al., 2011; IOM, 2008). Adult and child military family members who experience wartime deployments have been found to be at increased risk for symptoms of psychological disorders and for utilization of mental health services (Gorman et al., 2010; IOM, 2013; Mansfield et al., 2010; Paley et al., 2013). Families who experience the injury or death of service members are almost certain to experience at least some negative consequences.
The cost of treating psychological problems in service members and their families is consuming a growing share of the overall defense budget. Between 2007 and 2012 the cost of providing services for mental health treatments to active-duty and active National Guard and reserves more than doubled—from $468 million in fiscal year (FY) 2007 to $994 million in FY 2012. Overall, during this period DOD spent $4 billion on mental health treatment for activeduty service members and about $460 million on mental health treatment for activated National Guard and reserve members (Blakeley and Jansen, 2013).
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 (IOM, 2013). The IOM report, which was congressionally mandated under Section 1661 of the National Defense Authorization Act for FY 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 OIF or OEF; 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. The assessment of deployment-related health outcomes focused on traumatic brain injury, PTSD, depression, substance use disorders, and suicidal ideation, and included detailed discussions of the screening, assessment, and treatment of those conditions in DOD and the Department of Veterans Affairs (VA). However, that committee did not examine health promotion or the prevention of psychological disorders. Therefore, after that study was completed, DOD requested that the IOM conduct this follow-on study to assess these important aspects of health for service members and their families. Appendix A contains the executive summary of Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families (IOM, 2013).
The charge to the committee for this study evolved out of discussions between DOD and the IOM about how to improve psychological health in service members and their families. 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 (e.g., 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 from a variety of disciplines. The committee members have expertise in epidemiology, psychology, psychiatry, clinical medicine, prevention, evaluation, PTSD, depression, recovery support, substance use disorders, suicide, and interpersonal violence. A number of them also have knowledge of the workings of DOD and VA.
COMMITTEE’S APPROACH TO ITS CHARGE
The committee held 4 meetings over 7 months. In the first two meetings the committee held information-gathering sessions that were open to the public, and these meetings also included presentations from the sponsor, subject-matter experts from DOD, other government agencies, and military advocacy organizations (see Appendix B).
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. In its attempt to understand strategies to prevent negative psychological health outcomes and to uncover the latest evidence for different interventions and programs, the committee conducted extensive searches of the peer-reviewed and gray literature (including government and private-sector reports and Internet-
only resources). Research staff completed searches in PubMed, Cochrane Database of Systematic Reviews, OVID Medline, Embase, Scopus and PsycInfo databases using search terms that the committee had determined to be relevant to the charge. In addition, the committee’s search included two performance measurement databases—the NQF’s online database of quality measures, known as the Quality Positioning System, and the National Quality Measures Clearinghouse, maintained by the Agency for Healthcare Research and Quality.
This report is organized into six chapters and eight appendixes. Chapter 2 describes the conceptual frameworks that the committee used to approach its task of assessing resilience, reintegration, and various prevention programs intended to enhance psychological health and prevent psychological disorders in service members and their families. Chapter 3 provides information essential to understanding psychological health in the military as it relates to service members and their families. The chapter describes demographic data for Armed Forces personnel; major psychological health consequences experienced by service members deployed to OEF and OIF; effects of deployments on the psychological well-being of spouses and children of service members deployed to OEF and OIF; processes that DOD uses for assessing mental health risk in the military for its purposes of providing prevention, assessment, and treatment services; and an overview of mental health services in the military. Chapter 4 describes various DOD policies, programs, and services intended to enhance psychological health and prevent psychological health disorders among service members and their families. It also describes the nature of the interventions and reports on empirical studies that speak to the evidence for their effectiveness. Chapter 5 focuses on the committee’s task to identify the best performance measures for evaluating DOD resilience and prevention programs addressing psychological health. The chapter discusses the purposes of performance measurement, development and maintenance of performance measures, population health measurement, and DOD’s current efforts to measure program performance. The chapter includes a review of existing performance measures from national quality initiatives and provides measure examples to illustrate the measure concepts that are broadly applicable and essential to systematic assessment of prevention programs. Finally, the committee’s conclusions and recommendations are outlined in Chapter 6.
This report contains the following appendixes:
• Appendix A—Summary from Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families
• Appendix B—Information-Gathering Meeting Agenda
• Appendix C—Supplemental Health Screening Questionnaire
• Appendix D—Pre-Deployment Health Assessment Questionnaire
• Appendix E—Post-Deployment Health Assessment Questionnaire
• Appendix F—Post-Deployment Health Re-Assessment Questionnaire
• Appendix G—Program Reviews from Substance Use Disorders in the U.S. Armed Forces
• Appendix H—Table of DOD Programs to Increase Resilience or Prevent Psychological Health Problems, as Identified by RAND
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de Burgh, H. T., C. J. White, N. T. Fear, and A. C. Iversen. 2011. The impact of deployment to Iraq or Afghanistan on partners and wives of military personnel. International Review of Psychiatry 23(2):192–200.
Gorman, G. H., M. Eide, and E. Hisle-Gorman. 2010. Wartime military deployment and increased pediatric mental and behavioral health complaints. Pediatrics 126(6):1058–1066.
Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. New England Journal of Medicine 351(1):13–22.
Hoge, C. W., D. McGurk, J. L. Thomas, A. L. Cox, C. C. Engel, and C. A. Castro. 2008. Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine 358(5):453–463.
Hosek, J. 2011. How Is Deployment to Iraq and Afghanistan Affecting U.S. Service Members and Their Families? An Overview of Early Rand Research on the Topic. Santa Monica, CA: RAND Corporation.
IOM (Institute of Medicine). 2008. Gulf War and Health, Volume 6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Washington, DC: The National Academies Press.
———. 2013. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press.
MacLean, A., and G. H. Elder. 2007. Military service in the life-course. Annual Review of Sociology 33:175–196.
Mansfield, A. J., J. S. Kaufman, S. W. Marshall, B. N. Gaynes, J. P. Morrissey, and C. C. Engel. 2010. Deployment and the use of mental health services among U.S. Army wives. New England Journal of Medicine 362(2):101–109.
Paley, B., P. Lester, and C. Mogil. 2013. Family systems and ecological perspectives on the impact of deployment on military families. Clinical Child and Family Psychology Review 16(3):245–265.
Tanielian, T., and L. H. Jaycox. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation.
