6


FINDINGS AND RECOMMENDATIONS

The committee was asked by the Department of Defense (DOD) to conduct a systematic review and critique of DOD programs addressing resilience and reintegration and prevention strategies for psychological health problems including posttraumatic stress disorder, depression, substance abuse and recovery, suicide, and interpersonal violence—the committee specifically addressed violence in families and military sexual assault. Additionally, DOD tasked the committee with identifying various models for measuring performance of prevention programs and convening an information-sharing meeting of stakeholders and subject-matter experts associated with program evaluation and prevention efforts.

This chapter builds on the foundation laid in Chapters 15. The committee findings led to recommendations that could improve programs aimed at strengthening resilience and reintegration, the assessment of psychological health risk, the use of evidence-based interventions, and the implementation of measurement and evaluation strategies. Together, these recommendations are intended to improve programming to prevent the development of psychological health problems, including efforts to optimize resiliency, and to enhance the psychological health of service members and their families.

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 that have not been tested with military populations, particularly



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6 FINDINGS AND RECOMMENDATIONS The committee was asked by the Department of Defense (DOD) to conduct a systematic review and critique of DOD programs addressing resilience and reintegration and prevention strategies for psychological health problems including posttraumatic stress disorder, depression, substance abuse and recovery, suicide, and interpersonal violence—the committee specifically addressed violence in families and military sexual assault. Additionally, DOD tasked the committee with identifying various models for measuring performance of prevention programs and convening an information-sharing meeting of stakeholders and subject-matter experts associated with program evaluation and prevention efforts. This chapter builds on the foundation laid in Chapters 1–5. The committee findings led to recommendations that could improve programs aimed at strengthening resilience and reintegration, the assessment of psychological health risk, the use of evidence-based interventions, and the implementation of measurement and evaluation strategies. Together, these recommendations are intended to improve programming to prevent the development of psychological health problems, including efforts to optimize resiliency, and to enhance the psychological health of service members and their families. EFFECTIVENESS AND COST-EFFECTIVENESS Resilience, prevention, and reintegration interventions should be based on well- established 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 that have not been tested with military populations, particularly 165

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166 PREVENTING PSYCHOLOGICAL DISORDERS IN SERVICE MEMBERS AND THEIR FAMILIES in the case of programs that are family-focused or that 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, 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 as 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

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FINDINGS AND RECOMMENDATIONS 167 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 as 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 there is a need for DOD to improve approaches for identifying and intervening with those service members and those 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, post- deployment, 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.

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168 PREVENTING PSYCHOLOGICAL DISORDERS IN SERVICE MEMBERS AND THEIR FAMILIES 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. MILITARY FAMILIES 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 across 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 interventions, 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

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FINDINGS AND RECOMMENDATIONS 169 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, cost- effective, and culturally diverse. The reporting of these functions for transparency and accountability purposes is a critical component to ongoing program quality improvement.

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