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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
Returning Home from Iraq and Afghanistan
Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families
Committee on the Initial 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
Washington, D.C.
www.nap.edu
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
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 No. HHSP23320042509XI between the National Academy of Sciences and Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-14763-7
International Standard Book Number-10: 0-309-14763-8
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu.
Copyright 2010 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). 2010. Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe.
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
THE NATIONAL ACADEMIES
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.
www.national-academies.org.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
COMMITTEE ON THE INITIAL ASSESSMENT OF READJUSTMENT NEEDS OF MILITARY PERSONNEL, VETERANS, AND THEIR FAMILIES
GEORGE W. RUTHERFORD, MD, (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
DAN G. BLAZER, MD, PhD, J.P. Gibbons Professor of Psychiatry,
Duke University Medical Center
IBOLJA CERNAK, MD, ME, PhD, Medical Director,
Biomedicine Business Area, National Security Technology Department, Johns Hopkins University Applied Physics Laboratory
JOHN D. CORRIGAN, PhD, Professor and Director,
Division of Rehabilitation Psychology, Department of Physical Medicine and Rehabilitation, Ohio State University
RYAN D. EDWARDS, PhD, Assistant Professor of Economics,
Queens College and the Graduate Center, City University of New York;
Faculty Research Fellow,
National Bureau of Economic Research
SANDRO GALEA, MD, DrPH, Gelman Professor and Chair,
Department of Epidemiology, Columbia University Mailman School of Public Health
JANICE L. KRUPNICK, PhD, Professor and Director,
Trauma and Loss Program, Department of Psychiatry, Georgetown University
RICHARD A. KULKA, PhD, Group Vice President,
Survey Research, Abt Associates Inc.
BENNETT L. LEVENTHAL, MD,
Nathan Kline Institute for Psychiatric Research, Orangeburg, NY; Department of Child and Adolescent Psychiatry, New York University, and New York University Child Study Center
SHELLEY MACDERMID WADSWORTH, PhD, Professor of Family Studies; Director,
Center for Families;
Director,
Military Family Research Institute; Department of Child Development and Family Studies, Purdue University
ALAIR MACLEAN, PhD, Assistant Professor,
Department of Sociology, Washington State University
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.
ALBERT W. WU, MD, MPH, Professor,
Health Policy and Management, Johns Hopkins Bloomberg School of Public Health;
Professor of Medicine,
School of Medicine, Johns Hopkins University
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STUDY STAFF
CAROLYN FULCO, Scholar
NAOKO ISHIBE, Senior Program Officer
ROBERTA WEDGE, Senior Program Officer
RENEE WLODARCZYK, Senior Program Associate
PATRICK BAUR, Research Associate
JOE GOODMAN, Senior Program Assistant
NORMAN GROSSBLATT, Senior Editor
CHRISTIE BELL, Financial Officer
FREDRICK ERDTMANN, Director,
Board on the Health of Select Populations
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REVIEWERS
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 for 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 wish to thank the following individuals for their review of this report:
William R. Beardslee, Department of Psychiatry, Children’s Hospital of Boston
Linda Bilmes, Harvard Kennedy School, Harvard University
John Cawley, Department of Policy Analysis and Management, Cornell University
Archie R. Clemins, Caribou Technologies, Inc.
Colleen Conway-Welch, School of Nursing, Vanderbilt University
Meredith Kleykamp, Department of Sociology, University of Kansas
Kathryn Kotrla, Texas A&M Health Science Center in Round Rock
John A. Parrish, Center for Integration of Medicine and Innovative Technology, Boston
Penny F. Pierce, University of Michigan School of Nursing
Peter Rosen, University of Arizona Tucson School of Medicine
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 James S. House, Institute for Social Research, University of Michigan. Appointed by the National Research Council and the Institute of Medicine, he was 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 author committee and the institution.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
CONTENTS
PREFACE
xiii
ACRONYMS
xv
SUMMARY
1
Background
1
Statement of Task
2
Committee’s Approach to its Charge
2
Findings and Recommendations
3
Phase 2
8
1
INTRODUCTION
13
Background
14
Statement of Task
14
Committee’s Approach to Its Charge
14
Organization of the Report
16
References
16
2
OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM: DEMOGRAPHICS AND IMPACT
17
Demographics of the All-Volunteer Military
18
Operation Enduring Freedom and Operation Iraqi Freedom: Unique Characteristics
25
Current Impact on Operation Enduring Freedom and Operation Iraqi Freedom Service Members
29
Overview of Health Outcomes
29
Overview of Social Outcomes
30
Overview of Federal Readjustment Resources
33
Conclusion
34
References
34
3
SUMMARY OF FINDINGS FROM PREVIOUS CONFLICTS
39
From Ancient Greece and Rome to the Russo-Japanese War
40
World War I, World War II, and the Korean Conflict
41
The Vietnam War
42
Assessment of Exposure to Combat and Other War-Zone Stressors
43
Outcomes (Readjustment Problems)
44
Risk Factors for Readjustment Problems
48
The Persian Gulf War
49
Summary
50
References
54
4
PRELIMINARY FINDINGS
61
Consequences of Service in Operation Enduring Freedom and Operation Iraqi Freedom for Military Personnel and Their Families and Effects on Readjustment
61
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Traumatic Brain Injury and Related Blast Injuries
62
Polytrauma
65
Mental Health Disorders
66
Deployment
73
Deployment and Military Families
74
Deployment and Military Spouses
76
Deployment and Children
78
Deployment and Social Outcomes
80
Women and Minorities
86
Women
86
Ethnicity, Race, and Culture
90
Projecting the Lifelong Burden of War
93
References
98
5
THE CURRENT RESPONSE
117
Overview of Federal Benefits Available to Service Members, Veterans, and Their Families
117
The Department of Defense
117
The Department of Veterans Affairs
122
Overview of Programs and Services for Operation Enduring Freedom and Operation Iraqi Freedom Active-Duty Service Members, Veterans, and Their Families
128
Programs for Physical Needs
128
Programs for Mental Health Needs
132
Programs to Meet the Social Needs of Service Members, Veterans, and Their Families
138
Programs for National Guard and Reserve Members, Women, Minority-Group Members, and the Homeless
146
Summary
149
References
149
6
FINDINGS, RECOMMENDATIONS, AND PHASE 2
155
Findings and Recommendations
155
Phase 2
160
APPENDIX A
LEGISLATION
165
National Defense Authorization Act for Fiscal Year 2008, Public Law 110-181 110th Congress (2nd Session)
165
APPENDIX B
TOWN HALL MEETINGS
169
Killeen, Texas (Fort Hood): Army
169
Austin, Texas (Camp Mabry): Texas National Guard
170
Toledo, Ohio: Michigan, Indiana, and Ohio National Guard
171
Fayetteville, North Carolina (Fort Bragg): Army
171
Jacksonville, North Carolina (Camp Lejeune): Marine Corps
172
San Diego, California (Camp Pendleton): Marine Corps
172
Watertown, New York (Fort Drum): Army
173
Tables, Figures, and Boxes
TABLE 2.1
Service Members Deployed by Component as of April 30, 2009
17
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TABLE 2.2
Percentage of Active-Component Members by Age and Service Branch in 2009
19
TABLE 2.3
Percentage of Active-Component Members by Age and Service Branch in 2009
20
TABLE 2.4
Active-Component Members with Children by Service Branch in 2007
21
TABLE 2.5
Health-Care Priority Groups
33
TABLE 4.1
Racial and Ethnic Characteristics of Deployed Personnel to OEF and OIF from September 11, 2001, to the Present, First Deployment Only
91
TABLE 5.1
Veterans Integrated Service Networks and Numbers of Facilities
125
TABLE 5.2
Polytrauma System of Care
131
FIGURE 2.1a
Age of children (active component); FIGURE 2.1b Age of children (reserve component)
22
FIGURE 2.2
Counties of residence of deployed OEF and OIF Army (active-component) military personnel
23
FIGURE 2.3
Counties of residence of deployed OEF and OIF Army National Guard military personnel
24
FIGURE 2.4
Counties of residence of deployed OEF and OIF Army reserve military personnel
25
FIGURE 2.5
a Number of times deployed to OEF or OIF by branch of military service (active component)
27
FIGURE 2.6
Number of times deployed to OEF or OIF by branch of military service reserves)
27
FIGURE 2.7
Average time deployed in days by branch of military subdivided by active component and reserve component
28
FIGURE 2.8
Average dwell time in days by branch of military subdivided by active component and reserve component
28
FIGURE 4.1
Number of veterans on disability and pension payrolls by period of service
95
FIGURE 4.2
Total real spending on disability compensation and pensions for veterans by period of service
96
FIGURE 5.1
Physical Evaluation Board process
121
FIGURE 5.2
VA health-care enrollment process
124
FIGURE 5.3
Polytrauma facility locations (levels 1 and 2)
132
BOX 5.1
Family in the Military Context
119
BOX 5.2
VA PTSD Programs
138
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PREFACE
The committee has been asked to determine the physical and mental health and other readjustment needs of members and former members of the Armed Forces who were deployed in Afghanistan in Operation Enduring Freedom (OEF) or in Iraq in Operation Iraqi Freedom (OIF) and of their families and communities. The project is a two-part study. In this first phase, the committee has focused on the readjustment issues that have been commonly reported during the last several years in the scientific literature, in government and non-governmental reports, and in the popular press to gain a broad understanding of those issues. As part of its preliminary assessment, the committee has heard from active duty service members, veterans, and family members as it made several visits around the country.
The work has been humbling and eye opening. It has been gratifying to learn first-hand of the fortitude, resourcefulness, and bravery of active duty military personnel, Reserve and National Guard members, and their families. They have been proud to serve their country and if they have been wounded, physically or mentally, they expect their government to return the favor. In most cases, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) have responded to their needs admirably, but serious work remains.
Because the United States is still engaged in war in Afghanistan and Iraq, the situation regarding readjustment needs is an dynamic one. The committee applauds the efforts of the DOD and the VA in trying to respond to the situation, but in some instances the response has fallen short. In going around the country, the committee gathered qualitative data. It heard the same problems repeated on the West Coast and the East Coast, in the North and South, by health care providers, by active duty service men and women, and by veterans: there are not enough mental health providers to meet the demand, case managers and providers are overwhelmed, wait times are too long for appointments and between appointments for those in need of mental health and other services, confidentiality and stigma associated with seeking care for mental illness is a significant concern of active duty service members, job training and loss of jobs due to multiple deployments are issues, the ability to diagnose and treat traumatic brain injuries is a problem, and medical care for National Guard and reserve forces is an issue as they transition between active duty and civilian life.
In this preliminary report, the committee has looked broadly at the types of needs identified, including education, rehabilitation, employment training, mental health services, and other physical health services. In its second report, the committee will provide, in more detail, the extent of the services needed and will estimate costs on the basis of the services and the demographic data that it has received from the DOD and the VA.
The committee could not have completed its report without the help of the many people who provided data: those in the VA and the DOD, those in the veteran service organizations, researchers, and others working in the field. In addition, the people who helped us with our town hall and other meetings—on and off base—and all those who attended those meetings provided us with an understanding of the many complex issues.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families
I am deeply appreciative of the expert work of our committee members and their extraordinary commitment to the task. The committee extends its appreciation to the Institute of Medicine staff. In particular we would like to thank Naoko Ishibe, Renee Wlodarczyk, and Patrick Baur, who helped with myriad tasks, including literature searches, retrieving articles, providing information for background chapters, and contributing to the development of several chapters of the report. We appreciate Joe Goodman’s attention to our meeting and travel needs and Carolyn Fulco for her guidance and oversight.
George W. Rutherford, MD, AM
Chair, Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and their Families
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ACRONYMS
3CM Three Component Model of Care
ACAP Army Career and Alumni Program
ACWV Advisory Committee on Women Veterans
AFHSC Armed Forces Health Surveillance Center
AFSPP Air Force Suicide Prevention Program
APA American Psychological Association
APFT Army Physical Fitness Test
ASDHA Assistant Secretary of Defense for Health Affairs
AVF All-Volunteer Force
BHIE Bi-directional Health Information Exchange
BHOP Air Force Behavioral Health Optimization Project
BIRLS Beneficiary Identification and Record Locator System
BUMED Navy Bureau of Medicine and Surgery
CBO Congressional Budget Office
CBOC Community Based Outpatient Clinic
CDC US Centers for Disease Control and Prevention
CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs
CHCBP Continued Health Care Benefit Program
COSC Combat Operational Stress Control
CPRS Computerized Patient Record System
CRS Congressional Research Service
CSH Combat Support Hospital
CSIS Center for Strategic and International Studies
CWT Compensated Work Therapy
DCHV Domiciliary Care for Homeless Veterans
DCoE Defense Centers of Excellence
DEERS Defense Enrollment Eligibility Reporting System
DHCC Defense Health Clinical Center
DMDC Defense Manpower Data Center
DOD Department of Defense
DOL Department of Labor
DSM Diagnostic and Statistical Manual of Mental Disorders
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DTAP Disabled Transition Assistance Program
DUSDMCFP Deputy Under Secretary of Defense for Military Community and Family Policy
EPI Army Reserve Employer Partner Initiative
ESGR Employer Support of the Guard and Reserve
FAP Family Advocacy Program
FAST Family Advocacy Strengths-based Therapy
FRCP Federal Recovery Coordination Program
FY Fiscal Year
GAO Government Accounting Office
GDP Gross Domestic Product
HIV Human Immunodeficiency Virus
HMO Health Maintenance Organization
HUD Department of Housing and Urban Development
HVVP Hawaii Vietnam Veterans Project
IED Improvised Explosive Device
IOM Institute of Medicine
LOC Loss of Consciousness
MEB Medical Evaluation Board
MFLC Military and Family Life Counselor
MGIB-AD Montgomery GI Bill Active Duty
MGIB-SR Montgomery GI Bill Selected Reserve
MHAT Mental Health Advisory Team
MHM Military Historical Measure
MHS Military Health System
MOS Military Occupational Specialty
MREIDL Military Reservist Economic Impact Disaster Loan
MSIC Military Severely Injured Center
MST Military Sexual Trauma
MTF Military Treatment Facility
NCA National Cemetery Administration
NCSP National Call to Service Program
NDAA National Defense Authorization Act
NIH National Institutes of Health
NIMH National Institute of Mental Health
NVVRS National Vietnam Veterans Readjustment Study
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OMB Office of Management and Budget
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OSCAR Operation Stress Control and Readiness
PCM Primary Care Manager
PDH-CPG Post-Deployment Health Clinical Practice Guideline
PEB Physical Evaluation Board
PNS Polytrauma Network Site
PPO Preferred Provider Organization
PRC Polytrauma Rehabilitation Center
PTSD Posttraumatic Stress Disorder
RESPECT-Mil Re-Engineering Systems of Primary Care Treatment in the Military
SAC School Age Care program
SBA Small Business Administration
SCID Structured Clinical Interview for DSM Disorders
SE Supported Employment
SPC Suicide Prevention Coordinator
TAP Transition Assistance Program
TAPS Tragedy Assistance Program for Survivors
TBI Traumatic Brain Injury
TR Transitional Residence
UCX Unemployment Compensation for Ex-Servicemembers
USD(P&R) Under Secretary of Defense for Personnel and Readiness
USERRA Uniformed Services Employment and Reemployment Rights Act
VA Department of Veterans Affairs
VAMC VA Medical Center
VBA Veterans Benefits Administration
VECS Veterans Employment Coordination Service
VES Vietnam Experience Study
VETS Veterans’ Employment and Training Service
VETSA Vietnam Era Twin Study of Aging
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
VIST Visual Impairment Service Team
WWII World War II
WWRC Wounded Warrior Resource Center
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